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 2, an abbreviated on-site inspection, conducted on September 1, 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 were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, James A. Casey House, 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(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records on February 24-25, 2020, the facility failed to collect and document feedback forms for completed trainings in employee #1's record. Employee #1 was hired on April 1, 2013 and was promoted to the position of Project Director on June 15, 2016. The facility's training year that was reviewed was from January 1, 2019 to December 31, 2019. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/22/20 the clinical supervisor conducted a one hour in-house training session regarding staff training requirements, including mandatory training hours and available resources. All staff members were present, including the project director. A document verifying attendance was entered in each individual staff member's training file. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records on February 24-25, 2020, the facility failed to document the completion of 12 clock hours of annual training required for counselors in employee #1's record. Employee #1 was hired on April 1, 2013 and was promoted to the position of Project Director on June 15, 2016. The facility's training year that was reviewed was from January 1, 2019 to December 31, 2019. Employee #1's employee record only documented 1.5 hours of annual training for the training year reviewed.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/22/20 the clinical supervisor conducted a one hour in-house training session regarding staff training requirements, including mandatory training hours and available resources. All staff members were present, including the project director. A document verifying attendance was entered in each individual staff member's training file. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
705.2(2):Based on a physical site inspection on September 1, 2020, the facility failed to maintain the facility in a clean, safe, and in good repair for the safety and well-being of residents, employees and visitors as evidenced by the following:1)In Area 205, the rear fire exit window glass was broken. 2) In Area 199, apartment #2, a kitchen drawer was broken.These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the February 25, 2020 annual licensing inspection.
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Plan of Correction
The project director will notify the building maintenance manager that the Area 205 stairwell window is broken. The project director will authorize the maintenance manager to purchase, or order, any materials he deems necessary to repair the window. Upon completion the window will be inspected by the project director and repairs will be noted in the facility maintenance log.
The project director will notify the building maintenance staff that the kitchen cabinet drawer is broken. The project director will authorize the maintenance manager to purchase, or order, any materials needed to repair the drawer. Upon completion the cabinet drawer will be inspected by the project director and repairs will be noted in the facility maintenance log.
These repairs will be completed by 9/30/20. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a physical site inspection on September 1, 2020, the facility failed to maintain an area for drugs requiring special conditions. In the medication room refrigerator, a soda was being stored for staff usage. The findings were reviewed with facility staff during the licensing process. This is a repeat citation from the February 25, 2020 annual licensing inspection.
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Plan of Correction
The project director will strive to ensure that the refrigerator in the med room is not used to store food or drink items.
Previously, signs stating "no food or drink items" had been posted on the front door and on the wall above the refrigerator and they were still intact at the time of this inspection, and are still intact at this time. All med room staff will be firmly reminded that only medications and related items are to be stored in the refrigerator. The project director's previous policy was to randomly check the med room refrigerator to ensure policy compliance, as of 9/8/20 the project director shall ensure that the refrigerator is inspected daily by the med room attendants and that these inspections are documented on a clipboard attached to the refrigerator. |