INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 16, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Axiom Family Counseling Services, 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.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document an assessment of staff training needs, as required by regulation.
The findings include:
On August 16, 2011, the policy and procedure manual was reviewed. Per facility policy, the assessment of training needs will be completed in January each year. The regulation requires an assessment of staff training needs to be completed as a component of a staff development program. The facility failed to document the completion of a staff training needs assessment in January 2011 for the 2011 training year.
The president was interviewed on August 16, 2011. It was confirmed that an assessment of staff training needs was not completed to date.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the policy and procedure manual and an interview with the president, the facility failed to document an overall plan for addressing training needs.
The findings include:
On August 16, 2011, the policy and procedure manual was reviewed. Per the facility policy and procedure manual, a training plan will be completed after the summary of staff training needs. The regulation requires an overall plan for addressing training needs to be completed as a component of a staff development program. The facility failed to document the completion of an overall training plan.
The president was interviewed on August 16, 2011. The president confirmed that a plan for addressing training needs of staff was not completed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of an individual training plan in one of one personnel record, as required by regulation.
The findings include:
One personnel record was reviewed on August 16, 2011. An individual training plan was required to be documented in this personnel record. The facility did not document an individual training plan in personnel record # 1.
Employee #1 is the project/facility director and the sole employee for this D/A project. Employee #1 has a hire date of December 8, 2010. There was no documentation of an individual training plan in the personnel record of employee #1.
An interview with the president took place on August 16, 2011. It was confirmed that there was no documentation of an individual training plan in employee record #1.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of the fire extinguisher upon staff employment, in one of one personnel records.
The findings include:
One personnel record was reviewed on August 16, 2011. This employee required fire extinguisher training upon employment. Per regulation, the nonresidential facility shall instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel record # 1.
Employee # 1 is the project/facility director and was hired on December 8, 2010. There is no documentation that employee # 1 completed fire extinguisher training upon staff employment, as required.
The president was interviewed on August 16, 2011 and confirmed that employee # 1 had not completed fire extinguisher training.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies, in one of one personnel records.
The findings include:
One personnel record was reviewed on August 16, 2011. This personnel record was required to include documentation of emergency training. Per regulation, the nonresidential facility shall ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies. The facility failed to document the completion of emergency training in personnel record # 1.
Employee # 1 is the project/facility director and was hired on December 8, 2010. Verification of this training was not documented for employee # 1, at the time of the review on August 16, 2011.
The president was interviewed on August 16, 2011 and confirmed that personnel record #1 did not include documentation of emergency training.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs and an interview with the president, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The findings include:
Fire drill logs for the time period of January - August 2011 were reviewed. The fire drill logs that were documented did not include the exit route used and whether the fire alarm or smoke detector were operative in all of the fire drill logs reviewed.
An interview with the president was conducted on August 16, 2011. It was confirmed that the exit route used and whether the fire alarm or smoke detector was operative was not documented on the fire drill logs reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs and an interview with the president, the facility failed to prepare alternate exit routes to be used during fire drills, as required by regulation.
The findings include:
A review of the fire drill logs was conducted on August 16, 2011. The fire drills conducted from January - August 2011 were reviewed. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. The facility did not document any alternate exits used during fire drills. The exit route used during the fire drill was not documented for the drills conducted in January, February, March, April, May and June 2011.
An interview with the president was conducted on August 16, 2011. It was confirmed that the exit route used was not present on the aforementioned drills.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs, the facility failed to activate a fire alarm or smoke detector during each fire drill, as required by regulation.
The findings include:
The fire drill logs were reviewed on August 16, 2011. Per regulation, the nonresidential facility shall set off a fire alarm or smoke detector during each fire drill. The fire drill log was reviewed for documentation of fire drills from the time period of January to August 2011. The facility failed to document on the fire drill logs that a smoke detector or fire alarm had been activated for the monthly fire drills documented during this period.
The president was interviewed on August 16, 2011 and confirmed the fire alarm or smoke detector was not activated each month. The facility is located in a building with other occupants, and the fire systems cannot be activated because it would be a disruption to other occupants of the building. The president also indicated that no exception had been filed with the Division to request approval for use of an alternative method of alerting staff for purposes of conducting a fire drill.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records, the facility failed to document the results of a reference investigation in one of one personnel records.
The findings include:
One personnel record was reviewed on August 16, 2011. Per regulation, personnel records shall include the results of reference investigations. Personnel record #1 did not include the results of a reference investigation.
Employee # 1 is the project/facility director and was hired on December 8, 2010. There was no documentation of a reference investigation in personnel record # 1.
The president was interviewed on August 16, 2011 and confirmed there were no reference investigations documented for employee #1.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(d)(4) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(4) Salary information.
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Observations
Based on a review of personnel records, the facility failed to document salary information in one of one personnel records, as required by regulation.
The findings include:
One personnel record was reviewed on August 16, 2011. Per regulation, personnel records should include salary information. Personnel record #1 did not include documentation of salary information.
Employee #1 is the project/facility director and was hired on December 8, 2010. There was no documentation of salary information in personnel record #1.
The president was interviewed on August 16, 2011. It was confirmed that no salary information was documented in personnel record #1.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of personnel records, the facility failed to document written job descriptions which contained the employee's and supervisor's dated signatures in one of one personnel record.
The findings include:
One personnel record was reviewed on August 16, 2011. This record required documentation of a signed job description. The facility did not document a signed job description in personnel record #1.
Employee #1 is the project/facility director and was hired on December 8, 2010. There was no documentation of a signed job description in personnel record #1.
The president was interviewed on August 16, 2011. It was confirmed that there was no documentation of a job description in personnel record #1.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |