INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 17, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Project Transition, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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
Based on a review of personnel and training records, the facility failed to ensure that staff persons and/or volunteers received 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 as per the regulatory requirements in one of seven records reviewed.
The findings include:
Seven personnel records were reviewed on July 17, 2014 for documentation verifying the completion of the mandatory HIV/AIDs and TB/STD training's. One out of seven lacked documentation that the training's was completed as per the regulatory requirements.
Employee # 6 support staff person was hired on September 16, 2009. Employee #6 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by September 16, 2011. The training was not documented as of the date of the inspection.
The findings were confirmed by facility staff and corporate staff on June 17, 2014.
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Plan of Correction
The findings were reviewed by the Facility Director, Training and Development Manager, and the Director of Program Development, Quality and Compliance. The Training and Development Manager scheduled additional trainings for TB/STD on 08/01/14 and for HIV/AIDS on 08/15/14. The employees requiring TB/STD training have attended the training on 08/01/14 and all employees in need of the HIV/AIDS training are scheduled to attend on 08/15/14.
Plan to ensure this deficiency does not recur:
1. The Training and Development Manager and the Facility Director will ensure that all applicable new hires will complete TB/STD and HIV/AIDS trainings as part of the new hire process.
2. This information will be tracked in a central electronic database maintained by the Training and Development Manager.
3. The Training and Development Manger will work in collaboration with the Facility Director to identify and/or provide regular TB/STD and HIV/AIDS trainings for staff.
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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 record, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
The fire drill record was reviewed on July 17, 2014. The fire drills conducted from September 2013 - June 2014 were reviewed. The facility documented front and rear as exits used during each drill for the months of September 2013 through June 2014.
An interview with the facility director and corporate staff on July 17, 2014 confirmed the findings.
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Plan of Correction
The findings were reviewed by the Director of Program Development, Facility Director, and the Director of Facilities Management. The Facility director and Director of Facilities Management met with program staff and informed them that alternate exit routes are to be used during fire drills on an ongoing basis.
Plan to ensure deficiency does not recur:
1. The Facility Director will oversee all fire drills to ensure that alternate routes/exits are used and provide documentation that reflects this practice.
2. The Director of Program Development, Quality and Compliance will oversee Program Reviews which takes place every two months in which fire drill logs are audited.
3. The Director of Facilities Management will audit all program fire drills on a quarterly basis.
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709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the project ' s administrative paperwork, the project failed to complete an annual report for the fiscal year 2013.
The findings included:
The administrative documentation was reviewed on July 10, 2014. The annual report is to include a financial statement of income and expenses. The project failed to include the financial statement of income and expenses in the 2013 annual report.
An interview with the Director of Program Development, Quality, and Compliance on July 10, 2014 confirmed the findings.
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Plan of Correction
The findings were reviewed by the Director of Program Development, Quality and Compliance, Vice President of Quality and Program Fidelity, and the Chief Financial Officer. The financial statement of income and expenses was added to the Annual Report for fiscal year 2013 by the Chief Financial Officer.
Plan to ensure deficiency does not recur:
1. The Vice President of Quality and Program Fidelity will produce and sign off on the Annual Report and ensure that the financial statement including income and expenses is included
2. The Chief Financial Officer will review the Annual Report for accuracy before it is released.
3. The Director of Program Development, Quality and Compliance will do a final review of the Annual Report to ensure that all elements (including the financial statement) are included in the Annual Report.
Responsible Party: Chief Financial Officer, Director of Program Development, Quality and Compliance, Vice President of Quality and Program Fidelity.
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