INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on February 5, 2020. Based on the findings of the on-site inspection, Tpals Turning Point Alternative Living Solutions was found to not be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
The following deficiencies were identified during this inspection:
|
Plan of Correction
|
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.
|
Observations
During a review of staff records on February 5, 2020, the facility failed to have a sufficient number of staff persons trained in CPR and first aid, so that at least one person trained in these skills is onsite during the project's hours of operation.
Staff #3 provides counseling onsite alone and does not have CPR or first aid training.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Staff will be training in CPR and first aid on April 13th, 2020. During the interim, staff that is currently trained in CPR and first aid will be on site in Wilkes-Barre.
Clinical Supervisor will review staffing schedule weekly to oversee that this deficiency does not recur in the future. |
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.
|
Observations
During a review of staff records on February 5, 2020, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
Staff #3 was hired on November 18, 2019 as a counselor. Staff #3 had fire extinguisher training certificate, however there was no documented date when this training was completed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Staff members all receive fire extinguisher training within the first week of employment to comply with regulations.
Clinical Supervisor will appropriately document the fire extinguisher training for all staff within the first week that they are hired. Clinical Supervisor will document the date that the staff received the training.
Beginning on 2/10/2020, Project Director will review staff files on a quarterly basis to oversee Clinical Supervisor's documentation and ensure the dates have been documented appropriately throughout the year. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
During a review of staff records on February 5, 2020, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
Staff #3 was hired on November 18, 2019 as a counselor. Staff #3 had fire extinguisher training certificate, however there was no documented date when this training was completed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
on 3/1/2020. A training will be held for all staff members regarding evacuation strategy for fire drills.
Clinical Supervisor will document that staff have been trained on how to utilize a fire extinguisher as well as fire drill procedure. Client supervisor and staff will sign and date the document.
Project director will perform quarterly facility evaluations to ensure this documentation is in place and that this deficiency does not recur in the future. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
|
Observations
During an onsite inspection and review of records on February 5, 2020, the facility failed to conduct fire drills during normal staffing conditions.
There were no fire drills documented since the facility opened on September 25, 2019.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
on 3/1/2020. A training will be help for all staff members regarding evacuation strategy for fire drills.
Clinical Supervisor will perform unannounced monthly fire drills alternating to happen during all staff shifts.
The monthly drills will be appropriately documented by clinical supervisor to include date, time, length of evacuation, the method used to alert participants, the route of evacuation, and an evaluation of the procedure.
Project director will perform quarterly facility evaluations to ensure this documentation is in place and that this deficiency does not recur in the future. |
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.
|
Observations
During a review of staff records on February 5, 2020, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies.
There was no documentation that all personnel on all shifts were trained to perform assigned tasks during emergencies.
These findings were reviewed with facility staff during the licensing process
|
Plan of Correction
on 3/1/2020. A training will be help for all staff members regarding evacuation strategy for fire drills and how to perform tasks during emergencies.
Clinical supervisor will document the staff training.
Clinical Supervisor will perform unannounced monthly fire drills alternating to happen during all staff shifts.
The monthly drills will be appropriately documented by clinical supervisor to include date, time, length of evacuation, the method used to alert participants, the route of evacuation, and an evaluation of the procedure.
Project director will perform quarterly facility evaluations to ensure this documentation is in place and that this deficiency does not recur in the future. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
During an inspection and review of records on February 5, 2020, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
There were no documented fire drills since the facility opened on September 25, 2019.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
on 3/1/2020. A training will be help for all staff members regarding evacuation strategy for fire drills and how to perform tasks during emergencies.
Clinical supervisor will document the staff training.
Clinical Supervisor will perform unannounced monthly fire drills alternating to happen during all staff shifts.
The monthly drills will be appropriately documented by clinical supervisor to include date, time, length of evacuation, the method used to alert participants, the route of evacuation, and an evaluation of the procedure.
Project director will perform quarterly facility evaluations to ensure this documentation is in place and that this deficiency does not recur in the future. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
During an inspection and review of records on February 5, 2020, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
There were no documented fire drills since the facility opened on September 25, 2019.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
on 3/1/2020. A training will be help for all staff members regarding evacuation strategy for fire drills and how to perform tasks during emergencies.
Clinical supervisor will document the staff training.
Clinical Supervisor will perform unannounced monthly fire drills alternating to happen during all staff shifts.
The monthly drills will be appropriately documented by clinical supervisor to include date, time, length of evacuation, the method used to alert participants, the route of evacuation, and an evaluation of the procedure.
Project director will perform quarterly facility evaluations to ensure this documentation is in place and that this deficiency does not recur in the future. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
|
Observations
During an inspection and record review on February 5, 2020, the facility failed to conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
There were no documented fire drills since the facility opened on September 25, 2019.
These findings were reviewed with facility staff during the licensing process
|
Plan of Correction
on 3/1/2020. A training will be help for all staff members regarding evacuation strategy for fire drills and how to perform tasks during emergencies.
Clinical supervisor will document the staff training.
Clinical Supervisor will perform unannounced monthly fire drills alternating to happen during all staff shifts.
The monthly drills will be appropriately documented by clinical supervisor to include date, time, length of evacuation, the method used to alert participants, the route of evacuation, and an evaluation of the procedure.
Project director will perform quarterly facility evaluations to ensure this documentation is in place and that this deficiency does not recur in the future. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
During an inspection and record review on February 5, 2020, the facility failed to set off a fire alarm or smoke detector during each fire drill.
There were no documented fire drills since the facility opened on September 25, 2019.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
on 3/1/2020. A training will be help for all staff members regarding evacuation strategy for fire drills and how to perform tasks during emergencies.
Clinical supervisor will document the staff training.
Clinical Supervisor will perform unannounced monthly fire drills alternating to happen during all staff shifts.
The monthly drills will be appropriately documented by clinical supervisor to include date, time, length of evacuation, the method used to alert participants, the route of evacuation, and an evaluation of the procedure.
Project director will perform quarterly facility evaluations to ensure this documentation is in place and that this deficiency does not recur in the future. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
|
Observations
During an inspection and review of records on February 5, 2020, the unusual incidents policies and procedures failed to include implementation of a timely and appropriate corrective action plan, when indicated.
These findings were reviewed with the project staff during the licensing process.
|
Plan of Correction
On 2/10/2020, the policy and procedure for the unusual incidents documentation has been modified to include the following:
DOCUMENTATION REQUIREMENTS
1. All staff members are required to report any of the above incidents, immediately upon becoming aware of them, to their immediate supervisor.
2. The department supervisor will complete an investigation, to determine any known causes and supporting testimony (which may be collected in writing from other parties) and will prepare the DDAP required form (HD1062F), within 12 hours of being notified, and forward to the CEO for review and submission to DDAP within 72 hours, as required by regulation.
3. The CEO will identify any causal or contributing factors related to policy or procedures at TPALS and will develop an appropriate corrective action plan.
4. Upon completing the investigation, the CEO or designee will proscribe the corrective plan requirements including time-frame and personnel responsible for completion.
5. The CEO will monitor the corrective action plan on a quarterly basis to ensure the plan remains in place.
|
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
|
Observations
During an inspection and review of records on February 5, 2020, the unusual incidents policies and procedures failed to include ongoing monitoring of the corrective action plan.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
On 2/10/20 The following addition has been added to the unusual incident policy and procedure statement with the exact verbiage:
"#5.The CEO will monitor the corrective action plan on a quarterly basis to ensure the plan remains in place." |