INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on May 13, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Colonial Park Intensive Treatment 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)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of two personnel records, the project failed to provide documentation of providing CPR certification and first aid training to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Staff #2 is signing up for online American Red Cross CPR training course. Will complete training by 06/01/2020. Clinical Supervisor will ensure that all new staff members are up to date with CPR. Annual training plan reviews will require CPR active. |
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 two personnel records, the facility failed to provide documentation of fire extinguisher training upon hire for employee # 2.
Employee # 2 was hired as a counselor on March 20, 2020. There was no documentation of fire extinguisher training in the personnel record provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #2 was trained in the use of the fire extinguisher and completed the paperwork associated with fire safety on 05/22/2020. Clinical Supervisor will ensure that all new staff members will complete their fire safety training upon orientation. |
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 two personnel records, the facility failed to provide documentation of emergency training upon hire for employee # 2.
Employee # 2 was hired as a counselor on March 20, 2020. There was no documentation of emergency training in the personnel record provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff #2 received emergency training and completed the paperwork associated with emergency training on 05/22/2020. Clinical Supervisor will ensure that all new staff members will complete their fire safety training upon orientation. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of two personnel records, the facility failed to provide an annual performance evaluation for employee # 1.
Employee # 1 was hired as a Project/Facility Director on January 20, 2019. An annual performance evaluation was due on January 20, 2020 but had not been completed at the time of this review.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 will have an annual performance evaluation by their new supervisor no later than 6/30/2020. It will be responsibility of owner to ensure the annual training review of Facility Director is completed by 1/20/2021. Annual performance reviews will be rescheduled in owners schedule one year out at time of review to ensure the review happens annually by due date. |