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 July 23, 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, 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 personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that four of eight employees reviewed received the minimum of six hours of HIV/AIDS training and/or at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #5 was hired as a direct support professional on March 13, 2017 and was due to have the communicable disease trainings no later than March 13, 2019. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #6 was hired as a direct support professional on June 2, 2018 and was due to have the communicable disease trainings no later than June 2, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #7 was hired as a direct support professional on July 13, 2018 and was due to have the communicable disease trainings no later than July 13, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #8 was hired as an administrative assistant on November 15, 2017 and was due to have the communicable disease trainings no later than November 15, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Each employee in need of required DDAP trainings such as HIV/AIDS, will check the DDAP TMS site on a bi-weekly basis. They will identify trainings and associated dates they are available and submit request to the Clinical Director to attend. Clinical Director will make every effort to accommodate request by scheduling the employee accordingly. Additionally, the Clinical Director will check the DDAP TMS system on a monthly basis for all DDAP-required trainings and will assist in getting employees signed up for them. This plan and new procedure to ensure necessary staff training was communicated to staff during the weekly Staff Meeting on 8/6/2020.
Due to the nature of most DDAP and PCB authored trainings being cancelled within the past 6 months due to Coronavirus, the Corrective Action Date for this will be 12/31/2020.
To ensure this does not happen in the future, the Clinical director will meet with all new hires upon hire and explain the importance of this required training. Additionally, the Clinical Director will also research and identify accredited HIV/AIDS trainings that are offered virtually in an effort to ensure all employees are able to get this training completed in the required time from hire. Virtual trainings provide the opportunity to complete the training in a more timely manner as travel and expenses are then not a concern, and not at risk of being cancelled due to a health pandemic. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers 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 instruct all staff in the use of the fire extinguishers upon staff employment.
Employee #4 was hired on April 27, 2019 as a direct support professional and then promoted to a counselor assistant on February 10, 2020. This employee was not instructed in the use of the fire extinguisher until July 11, 2019.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
As part of the on-boarding process, all employees hired at LCL will complete the required Fire Extinguisher and Fire Safety training within their first 72 hours of working. Their completion of the training will be documented with a certificate and the training evaluation form will go directly into the Clinical Director's mailbox in an effort to ensure it is completed within 72 working hours of hire. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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.
Employee #4 was hired on April 27, 2019 as a direct support professional and then promoted to a counselor assistant on February 10, 2020. This employee was not trained to preform assigned task during emergencies until July 11, 2019.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
As part of the on-boarding process, all employees hired at LCL will complete the required Fire Extinguisher and Fire Safety training within their first 72 hours of working. Their completion of the training will be documented with a certificate and the training evaluation form will go directly into the Clinical Director's mailbox in an effort to ensure it is completed within 72 working hours of hire. This was communicated to all staff at the weekly Staff Meeting on 8/6/2020. |