INITIAL COMMENTS
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28 Pa. Code subsection 709.14(a)(5) Restriction on License. Authorized capacity. On June 6, 2006 through June 8, 2006 the facility had a census of 433 for the outpatient activity which exceeds the authorized maximum capacity of 400.
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Plan of Correction
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INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 6, 2006 through June 8, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on July 12, 2006.
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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
Employee #8 on the Department of Health training file review form did not meet the general training requirements within one year of the date of hire. The training attended on May 1, 2006 is not approved by the Department and could not be counted.
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Plan of Correction
The employee missed the previous available training due to an illness. We believed the Laban training was OK since it is approved by the PCB.The employee will attend the first available HIV training (more than likely facilitated by the local Red Cross).
The Executive Director will oversee this process. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Four of fourteen counselors' caseloads are in excess of thirty five clients.
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Plan of Correction
Obviuos lack of oversight by the supervisory staff. Currently everyone has a maximum 35 clients. Supervisory staff were re-educated as to the staff to client ratio. The Clinical Director will have direct ongoing oversight of the appropriate ratio. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Two of three bathrooms have windows that are not accessible and have no exhaust fans. One of three bathrooms had no window and no exhaust fans. The bathrooms are not ventilated as required.
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Plan of Correction
The physical plant of the Agency continues to be upgraded and has been over the past several months. As of June 16th all bathrooms have exhaust fans. |