INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the March 14-15, 2012 licensure renewal inspection. The follow-up inspection was conducted on September 19, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, The Gate House For Men 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(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's policy and procedures and administrative documentation, the facility failed to document an overall plan for addressing training needs, as required by regulation.
The findings include:
On March 14, 2012, the facility's policy and procedures were reviewed. Per the agency policy and procedure,"a fiscal year training calendar will be kept by Program Directors indicating all staff training topics, dates, and presenters, etc. This information will be submitted by the end of the fiscal year to the Chief Executive Officer for use in developing an overall annual training assessment report." The regulation requires an overall plan for addressing training needs to be completed as a component of a staff development program. On March 15, 2012, the project/facility director was requested to provide documentation of the overall training plan. The facility's annual report was presented, however, it did not include an overall training plan for the 2011/2012 overall training plan. The facility failed to document the completion of an overall training plan.
The project/facility director was interviewed on March 15, 2012. The project/facility director confirmed that an overall plan for addressing training needs was not completed.
This was still out of compliance at the time of the follow-up conducted on September 19, 2012.
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Plan of Correction
Based on the annual evaluation of the overall training plan of the preceding year and the needs of the individual staff members, the project director will develop the overall training plan for each training year by July 15th of the new training year. This plan will address training subjects, trainers, and proposed training dates.
The program director will ensure the overall training plan for the year is completed by July 15th of the new training year, ensuring this deficiency does not recur. It will become part of the annual executive summary of quality improvement and reported to the H.E.A.R., Inc. Board of Directors at their July meeting which occurs the third Wednesday in July.
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705.9 (4) (iii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(iii) The evacuation and transfer of residents impaired by alcohol or other drugs.
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Observations
Based on the review of the facility's policy and procedures, the facility failed to document written procedures for staff and residents to follow in case of an emergency that included provisions for the evacuation and transfer of residents impaired by alcohol or other drugs.
The findings include:
The facility's policy and procedures were reviewed on March 14, 2012. The project/facility director was asked to provide the procedure for the evacuation and transfer of residents that are impaired by alcohol or other drugs. The project/facility director was unable to provide written procedures. The finding was not disputed.
This was still out of compliance at the time of the follow-up conducted on September 19, 2012.
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Plan of Correction
The policy has been amended to include the evacuation and transfer of residents impaired by alcohol and other drugs in emergency situations. The amended policy includes staff responsibilities regarding the care and evacuation of impaired residents and the arrangement of transportation to a safe meeting place or facility.
Being a misinterpreted standard, the policy sited did not address the standard. The amended policy has been reviewed with all staff to assure that its application is understood by all and assures a violation of the standard does not occur. Since this deficiency is not about an occurrence, rather a misinterpretation of the standard in writing the policy, further citations will not occur through the amended policy that has been board approved.
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