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 1, an abbreviated off-site inspection, conducted on August 24, 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, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Gateway Greensburg 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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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.
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Observations
The facility failed to document fire extinguisher training upon staff employment in employee record # 6.
Employee # 6 was hired March 2, 2020. Fire extinguisher training was not documented until March 17, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All managerial staff will be re-educated on the need to orient staff to fire extinguisher location and use, and emergency training, upon employment. HR staff will monitor completion of orientation checklist detailing completion of these two trainings. Site manager, program director, and Vice President of Human Resources will monitor all new staff to ensure they have received required training. Managerial staff will be re-educated by 10/15/20. HR staff will begin monitoring immediately. |
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.
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Observations
The facility failed to document that all personnel on all shifts were trained to perform assigned tasks during emergencies in employee record # 6.
Employee # 6 did not have documentation of emergency training upon employment for their assigned shift.
Employee # 6 was hired March 2, 2020. Emergency training was not documented until March 17, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All managerial staff will be re-educated on the need to orient staff to fire extinguisher location and use, and emergency training upon employment. HR staff will monitor completion of orientation checklist detailing completion of these two trainings. Site manager, program director, and Vice President of Human Resources will monitor all new staff to ensure they have received required training. Managerial staff will be re-educated by 10/15/20. HR staff will begin monitoring immediately. |