INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 19, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Caron Treatment Centers - Detox Unit was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Four personnel records were reviewed for documentation of HIV/AIDS and TB/STD training on January 17-18, 2017. The facility failed to provide documentation of required HIV/AIDS and TB/STD training in employee records # 3 and 4.
Employee # 3 was hired by the project on 1/19/15 and is a certified medical assistant. HIV/AIDS and TB/STD training was due to be completed by 1/19/17. The facility failed to provide documentation of this training for the employee.
Employee # 4 was hired by the project on 12/1/14 and is a certified medical assistant. HIV/AIDS and TB/STD training was due to be completed by 12/1/16. The facility failed to provide documentation of this training for the employee.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All employees who are currently out of compliance with mandatory communicable disease training will be notified of delinquency. Additional HIV/AIDS and TB/STD training will be offered and all delinquent staff will be required to schedule and attend.
HR will be notified of all employees who remained deficient from previous year.
Supervisors will address employees who remain out of compliance with possible disciplinary action.
An error in the learning management system was corrected, which did not accurately display the required communicable disease trainings for Employee #4. This has since been corrected and staff has been notified of outstanding trainings.
The coordinator of training is responsible for ensuring training adherence.
Estimated completion date is July 1, 2017. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
A physical plant inspection was conducted on January 19, 2017. The facility failed to ensure hot water temperatures did not exceed 120 in all bathrooms.
In Building 100 the water temperatures in the follow rooms exceeded 120 Room #124 bathroom water temperature was 124.3
* Room #129 bathroom water temperature was 122.4 information was reviewed with facility staff during the licensing process.
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Plan of Correction
Rebuild mixing valves to ensure domestic water is in correct temperature range throughout building. Lower holding temperature in hot water storage tanks. Director of Plant Operations is responsible for the implementation of this Plan of Correction.
3/3/17: Revised plan of correction in response of deficiency 23W611-PO59 :
1. Rebuild mixing valves on a bi-annual basis.
2. Lower the temperature of the hot water holding tank.
3. Create preventative maintenance work order to check domestic hot water temperature to maintain less than 120 degrees Fahrenheit on a quarterly basis.
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709.2(a) LICENSURE Subchapter A.General Provisions.Policy
709.2. Policy.
(a) Persons, partnerships and corporations, or other legal entities intending to provide drug and alcohol treatment services, shall first be licensed by the Department.
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Observations
Interviews with staff were conducted during the licensing inspection. Based on these interviews, Caron Treatment Centers - Detox Unit has implemented the use of Buprenorphine detoxification/taper protocols for the patients transferred to the inpatient non-hospital residential treatment and rehabilitation activity.
Caron Treatment Centers - Detox Unit is not licensed to provide Buprenorphine on an outpatient basis at this location.
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Plan of Correction
A request to add narcotic treatment activities to our inpatient non-hospital license 062041 is being submitted on 2/27/17. This was recommended by Patricia DeLeo.
Nancy Diener, Director of Nursing is responsible for implementation of this corrective action. |