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 April 17, 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, Sojourner House 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
The facility failed to document TB/STD training within the first year of employment for counselor #4.
Counselor #4 was hired on January 21, 2019. TB/STD training was due to be completed by January 21, 2020. At the time of the offsite inspection, April 17, 2020, there was no documentation of TB/STD training for counselor #4.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselor #4 found the training certificate for the missing training. Counselor #4 had emailed to Human Resources for documentation as required. Human Resources did not see it. New staff will continue to follow procedure of completing required trainings within 1 year of hire. New staff will forward training certificates to Human Resources and immediate supervisor for documentation and record keeping. Supervisors will review required trainings and ongoing training hours during employee supervisions weekly or bi-weekly, and Training Assessments are completed once per year. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to document unannounced fire drills at least once a month.
The fire drills logs for the time period of February 2019 - March 2020 were reviewed during an offsite inspection on April 17, 2020. There was no documentation of a fire drill for the month of March 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Drills will be completed monthly and properly documented. Program Manager and Recovery Support Specialist Lead will Review the monthly Fire Drill forms on the 15th and end of each month to make sure they have been completed. They will initial the back of the sheet as proof that they reviewed the documents. In the case the Program Manager is on medical or family leave, the Program Director and Recovery Support Specialist Lead will make sure the Fire Drills are completed in the middle of the month and again at the end of the month. All fire drill documentation will be emailed to the Program Director to save as well. |