This report is a result of an onsite follow-up inspection regarding the plans of correction for the June 7 through June 9, 2010 licensure renewal inspection. The follow-up inspection was conducted on March 4, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, BGI of Brandywine, Inc. 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 and a plan of correction is due on April 28, 2011.
|
Plan of Correction
|
Observations
Based on a review of personnel training records and an interview with the facility director, the facility failed to provide documentation of TB/STD training in three out of six personnel training records, as required by regulation. Also, two out of six personnel failed to have HIV/AIDS training.
The findings include:
Twenty-one personnel training records were reviewed on March 4, 2011. Six personnel were required to have documentation of TB/STD training. Per regulation, staff persons shall receive a minimum of 4 hours of TB/STD training and 6 hours of HIV/AIDS training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training with the first 2 years of employment. The facility did not provide documentation of TB/STD training in personnel training records # 6, 7, and 8. The facility did not provide H IV/AIDS training in personnel training records # 4 and 8.
Employee # 4 is support staff and was hired 2/19/2008. HIV/AIDS training was due to be completed no later than 2/19/2010. The facility failed to provide documentation of HIV/AIDS training.
Employee # 6 is support staff and was hired 4/25/2007. TB/STD training was due to be completed no later than 4/25/2009. The facility failed to provide documentation of TB/STD training.
Employee # 7 is support staff and was hired 10/12/2007. TB/STD training was due to be completed no later than 10/12/2009. The facility failed to provide documentation of TB/STD training.
Employee # 8 is support staff and was hired 6/9/2008. TB/STD and HIV/AIDS training was due to be completed no later than 6/9/2010. The facility failed to provide documentation of TB/STD and HIV/AIDS training
The facility director was interviewed on March 4, 2011 and confirmed that these employees had not completed TB/STD and/or HIV/ AIDS training. This is a repeat citation from the licensing inspection conducted on June 7 through June 9, 2010.
|
Plan of Correction
On site training for HIV conducted 4/5/2011. TB/STD training will be conducted on site by May 31, 2011. Those staff members out of compliance will be placed on an Employee Improvement Plan to assure compliance. HR Coordinator responsible for identifying deadlines for new hires and departmental managers are responsible to assure their staff are compliant.
Moving forward these trainings will be held on site 2 x per year in 6 month increments. |