INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 1-2, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago - Pottsville 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
Nine personnel records were reviewed on August 1, 2016. The facility failed to provide documentation of completed HIV/AIDS and TB/STD training for employee # 5. Employee # 5 was hired as a counselor on June 24, 2015. HIV/AIDS and TB/STD training was due to be completed no later than June 24, 2016. The facility failed to document the completion of this training. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #5 is scheduled to complete HIV/AIDS training on August 11, 2016 and TB/STD training on September 1, 2016. The facility director will monitor training completion through the new HR system on a monthly basis beginning on October 1, 2016 to ensure ongoing compliance. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
A physical plant inspection was conducted on August 2, 2016. Black mold was observed in the shower stall of the bathroom on the 3rd floor in the male inpatient unit. Specifically, the black mold was concentrated along areas of caulking in the shower stall. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The mold in the shower stall on the 3rd floor was removed and the shower re-caulked on August 4, 2016. The facility director will monitor the cleanliness of the facility during weekly sanitation site inspections to ensure ongoing compliance on August 29, 2016 |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Administrative documentation was reviewed during the narcotic treatment program inspection on August 1-2, 2016. The administrative documentation provided failed to verify that the facility provides physician services at least 1 hour per week onsite for every ten patients. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will begin tracking physician service hours in a daily log beginning on August 15, 2016. The facility director will monitor ongoing compliance on a weekly basis beginning on August 22, 2016. |
715.14(c) LICENSURE Urine testing
(c) A narcotic treatment program shall develop and implement policies and procedures to minimize misidentification of urine specimens and to ensure that the tested specimens can be traced to the donor.
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Observations
Six client records for detoxification with Buprenorphine were reviewed on August 1-2, 2016. A review of the client records indicated that the facility failed to consistently implement their policies and procedures for urinalysis protocols. The facility's policy for urinalysis protocols states that nursing staff will label each urinalysis testing component with the client's first and last name, client's date of birth, and client's gender. The facility failed to demonstrate consistent implementation of this policy for all six detox records reviewed. Each client record documented a photocopy of the urinalysis testing components. For client records # 1, 2, 4, and 6, the testing components were labeled with only the client's first name. For client record # 3, the testing components were labeled with the client's first name and last name initial. For client record # 5, the testing components were labeled with the client's first name, last name initial, and the date the urinalysis was taken. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corporate clinical director reviewed narcotic treatment protocols concerning client identification labeling of urinalysis testing components on August 9, 2016 with the facility nursing staff to ensure appropriate completion. The facility director will monitor weekly through regular clinical chart reviews beginning on August 12, 2016 to ensure ongoing compliance. |