INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 16-17, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Little Creek Lodge, LLC 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 a review of the facility's Staffing Requirements Facility Summary Report (SRFSR) and an interview with the Project Director and Clinical Supervisor, the project failed to ensure that all personnel received a minimum of 6 hours of HIV/AIDS and/or at least 4 hours of TB/STD and other health related topics training using a Department approved curriculum within the regulatory timeframe.
The findings include:
The facility failed to ensure that six of the employees completed the required training.
Employee #5 was hired as a driver on October 21, 2008. HIV/AIDS training and TB/STD and other health related topics training were due to be completed no later than October 21, 2010. As of the date of the inspection, there was no documentation in the employee's file indicating that the HIV/AIDS training was completed.
Employee #6 was hired as a chef on October 28, 2011. HIV/AIDS training and TB/STD and other health related topics training were due to be completed no later than October 28, 2013. As of the date of the inspection, there was no documentation in the employee's file indicating that the HIV/AIDS training was completed.
Employee #7 was hired as a Residential Care Worker on March 21, 2012. HIV/AIDS training and TB/STD and other health related topics training were due to be completed no later than March 21, 2014. As of the date of the inspection, there was no documentation in the employee's file indicating that the HIV/AIDS training was completed.
Employee #8 was hired as a Residential Care Worker on March 27, 2012. HIV/AIDS training and TB/STD and other health related topics training were due to be completed no later than March 27, 2014. As of the date of the inspection, there was no documentation in the employee's file indicating that the HIV/AIDS training was completed.
Employee #9 was hired as a Contracted Employee-Substitute Chef on April 1, 2010. HIV/AIDS training and TB/STD and other health related topics training were due to be completed no later than April 1, 2012. As of the date of the inspection, there was no documentation in the employee's file indicating that both the HIV/AIDS training and the TB/STD and other health related topics training were completed.
Employee #10 was hired as a Residential Care Worker on February 18, 2009. HIV/AIDS training and TB/STD and other health related topics training were due to be completed no later than February 18, 2011. As of the date of the inspection, there was no documentation in the employee's file indicating that the HIV/AIDS training was completed.
The Project Director and the Clinical Supervisor confirmed the findings during an interview on July 16, 2014.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an on-site licensure renewal inspection conducted from July 16-17 in the application of Regulation 704.11 (C)(1).
The Clinical Director will schedule Trainings for HIV/AIDS and TB/STDÕs for all staff needing said trainings. Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations for General Training Requirements. All staff needing these trainings will have them by 12/31/14
To ensure that this does not reoccur Clinical Director will review all staff training records quarterly to ensure all staff have appropriate trainings as required. Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations.
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705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on a review of the facility's fire drill record, the facility failed to conduct fire drills on different days of the week.
The findings include:
The fire drill record was reviewed on July 16, 2014, for the period of September 1, 2013 through June 30, 2014. The facility conducted a total of ten fire drills in the period reviewed and five out of the ten fire drills were conducted on a Friday. The other five fire drills were conducted on Monday-(2), Wednesday-(2), and Thursday-(1).
The Project Director and the Clinical Supervisor confirmed the findings.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an on-site licensure renewal inspection conducted from July 16-17 in the application of Regulation 705.10.(d)(7)
The Clinical Director will develop a fire drill schedule that will ensure that drills are preformed evenly throughout the days of the week. Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations. This schedule will be implemented on 7/28/14
To ensure that this does not reoccur Clinical Director will review fire drill log book monthly to ensure the schedule is being followed. Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations.
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information for the release of information was obtained from the client prior to the disclosure of information contained in the client record.
The findings included:
Twelve client records requiring proper releases of information were reviewed on July 16 through 17, 2014. The facility failed to ensure that an informed and voluntary consent to release information was obtained in one client record reviewed, #9.
Client #9 was admitted to treatment on 02/26/2014 and was discharged on 05/26/2014. A letter was faxed on March 3, 2014 to an attorney; however, there was no informed and voluntary consent to release information form signed by the client in the client's record.
The Clinical Supervisor confirmed the findings.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an on-site licensure renewal inspection conducted from July 16-17 in the application of Regulation 709.28(C).
The Clinical Director will schedule Training on Confidentiality and Release of information forms for all clinical staff. Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations for General Training Requirements. All staff needing these trainings will have them by 8/21/14
To ensure that this does not reoccur Clinical Director will review all client charts monthly to ensure the confidentiality of client information and that all release of information forms have been completed as required. All future hires will be given the training upon hire. Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations.
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