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.
Part 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.
Part 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 12, 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, DARS, Inc, Supervised Independent Living Program 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
Based on a review of 21 staff listed on the Staffing Requirement Facility Summary Report provided by the facility on August 12, 2020, the facility failed to provide documentation that employee #20 received the minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #20 was hired on August 30, 2017 as a Youth Care Worker and needed to have HIV/AIDS and TB/STD trainings no later than August 30, 2019. There was no documentation of this at the time of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will insure that the Clinical staff receive the minimum hours DDAP requires of training for communicable diseases HIV/Aids and TB/STD's in the first year of employment. The Youthcare Supervisor will see that all support staff receive the necessary trainings completed in the first two years of employment according to the DDAP regulations for the communicable diseases of HIV/Aids and TB/STD's. Employee#20 will receive TB/STD's and HIV/Aids training in the next three months of the corrective action date. If an in-person training is not available due to the Covid-19 Pandemic, an online platform will be evaluated to complete the training. The Program Director will have the overall responsibility for overseeing that citation 0067 is rectified going forward. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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.
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Observations
Based on a review of ten fire drills from November 2019 through July 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.
The facility failed to document whether the fire alarm or smoke detector were operative on fire drills dated May 19, 2020 and June 23, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In reference to citation #P147, the SIL Program Director (Designated DARS Fire Marshall)will oversee that each fire drill record indicates whether the fire alarm or smoke detector was utilized for the fire drill. This will be attested by the DARS.,Inc. Executive Director. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of ten fire drills from November 2019 through July 2020, the facility failed to set off a fire alarm or smoke detector during each fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For citation P155, the SIL Program Director edited the Fire Drill Record indicating that a 24 hour monitoring service (Able Security)is utilized to insure that our entire fire emergency system operation is fully functional. If there is an error in fire system, the Executive Director, DARS Maintenance, and the On-call staff are notified immediately for corrective action. Also, the fire drill record will indicate during the scheduled fire drills that the drill was placed on a test mode so the fire alarm can be used without dispatching the emergency services. |