INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 9, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Center For Families 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
Based on the review of the facility-submitted Staffing Facility Requirements Summary Report and personnel records, the facility failed to ensure that all employees received a minimum of six hours of HIV/AIDS training and at least four hours of TB/STD training within the regulatory timeframe.
Employee #5 was hired as a counselor on October 3, 2019 and was due to have the HIV/AIDS training and the STD training no later than October 3, 2020; however, the trainings were not completed until May 6, 2021 and May 3, 2021, respectively.
Employee #6 was hired as a counselor on September 16, 2019 and was due to have the HIV/AIDS training and the STD training no later than September 16, 2020; however, the trainings were not completed until May 6, 2021 and May 5, 2021, respectively.
Employee #7 was hired as a counselor on January 31, 2020 and was due to have the HIV/AIDS training and the STD training no later than January 31, 2021; however, the trainings were not completed until May 6, 2021 and May 3, 2021, respectively.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Met with Gwenn Mascoli to review guidelines for HIV/AIDS training. Determined and communicated to compliance officer Erin Ziegelmeyer and human resources that all HIV/AIDs training moving forward will be conducted at start of employment. |
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 the May 2020 through May 2021 fire drill log, the facility failed to identify, on the fire drill log, which exit route was used during each fire drill conducted.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Met with lead CC 6/10/2021 and reviewed Fire Drill Log and demonstrated proper completion of exit route. Next Fire Drill schedule 7/7/21 whereby route will be completed. |