INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 18, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Sanctuary 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of administrative documents submitted and one personnel record, the facility failed to develop a written individual training plan with one employee.
Employee #1 was hired as the Project Director/Facility Director on December 1, 2021 and was current in that position at the time of the inspection. Employee #1 ' s initial individual training plan was not developed until March 1, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director performed a
review of regulations, licensing alerts, Sanctuary House Policy and Procedure as well as the personnel file of Employee #1 in accordance with this deficiency.
Licensing alert 03-05 to PA code 704.11(b)(1) calls for a written individual training plan to be completed within 30 days of hire. This alert was not a part of policy at Sanctuary House at time of Employee #1's hire.
The Project Director has corrected this deficiency immediately by updating Sanctuary House Policy and Procedures to now require all employees to have written individual training plans within 30 days of hire date.
Further, Project Director will monitor DDAP website for all Licensing Alert updates and update Sanctuary House policy and procedures accordingly on an annual basis to ensure ongoing compliance.
Additionally, a new check off item has been added to the New Staff Orientation Checklist that calls for verification that the written individual training plan has been completed within 30 days of hire. Administrator will review and confirm training plan completion as part of normal duties. |
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 the review of one personnel record, the facility failed to instruct one staff in the use of the fire extinguishers upon staff employment.
Employee #1 was hired as the Project Director/Facility Director on December 1, 2021 and was current in that position at the time of the inspection. Employee #1 did not receive instruction in the use of the fire extinguisher until January 20, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has performed a review of Sanctuary House Policy and Procedures in accordance with this deficiency.
Project Director has updated the policy and procedures to reflect that all staff will be trained on proper use of the fire extinguisher upon hire and such training will be documented in each employee's personnel file.
Compliance with this standard is effective immediately.
Further, Project Director will review employee on-boarding processes with Administrator and ensure that all required trainings and orientations are performed in necessary time frames. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on the review of administrative documents, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
There was not a documented financial audit for the 2021 year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has performed a review with the governing body of Sanctuary House in accordance with this deficiency.
The Project Director and Governing Body will ensure that an independent financial audit is performed on an annual basis consistent with the fiscal year of the organization.
The Sanctuary House operates on a calendar year fiscal and as such will have a financial audit for services rendered in the previous year available by July 1 of the following year.
Further, Administrator has directed the independent accountant for The Sanctuary House to prepare a fiscal audit for operating year 2021. This will be completed by December 31, 2022.
Compliance with this standard is effective immediately.
Further, Project Director will follow up with Governing Body on an annual basis to ensure ongoing compliance with this standard.
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709.26 (c) LICENSURE Personnel management.
§ 709.26. Personnel management.
(c) There shall be written job descriptions for project positions.
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Observations
Based on the review of administrative documents, the facility failed to have written job descriptions for project positions.
There was not a job description for the facility director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has reviewed
Sanctuary House Policy and
Procedures in accordance with this
deficiency.
An update has been made to the Sanctuary House Policy and Procedures to now include a job description for the facility director.
Compliance with this standard is effective immediately.
Further, Project Director will review personnel management practices with the Administrator on an annual basis to ensure ongoing compliance with this standard. |
709.54(a)(3) LICENSURE Proper preparation of food
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(3) Proper preparation of food.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop written procedures for its dietetic services which include to proper preparation of food that followed the regulatory temperatures for keeping food hot and cold. The temperatures in the procedures allowed for cold food to be kept higher than 40F and hot food to be kept below 140F.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has reviewed
the Sanctuary House policy and
Procedures in accordance with this deficiency.
The Sanctuary House Policy and Procedures had incorrect regulatory temperatures for keeping food hot and cold. The Project Director has updated this policy, correcting the previous typographical errors so that it ensures "Cold Foods" will be maintained at a temperature of 40° Fahrenheit or colder and "Hot Foods" will be maintained at 140° Fahrenheit or higher.
Compliance with this standard is effective immediately.
Further, the Project Director will provide oversight of staff to ensure that food preparation regulation temperatures are adhered to. |