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 July 23, 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, Little Creek Outpatient Services, 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(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 personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employee #3 receuve a minimum of six hours of HIV/AIDS training within the regulatory timeframe.
Employee # 3 was hired as a counselor assistant on December 31, 2018 and was due to have the communicable disease trainings no later than December 31, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Each employee in need of required DDAP trainings such as HIV/AIDS, will check the DDAP TMS site on a bi-weekly basis. They will identify trainings and associated dates they are available and submit request to the Clinical Director to attend. Clinical Director will make every effort to accommodate request by scheduling the employee accordingly. Additionally, the Clinical Director will check the DDAP TMS system on a monthly basis for all DDAP-required trainings and will assist in getting employees signed up for them.
This plan was rolled out during a Staff Meeting on 8/6/2020. Due to the nature of most DDAP and PCB authored trainings being cancelled within the past 6 months due to Coronavirus, the Corrective Action Date for this will be 12/31/2020.
To ensure this does not happen in the future, the Clinical director will meet with all new hires upon hire and explain the importance of this required training. Additionally, the Clinical Director will also research and identify accredited HIV/AIDS trainings that are offered virtually in an effort to ensure all employees are able to get this training completed in the required time from hire. Virtual trainings provide the opportunity to complete the training in a more timely manner as travel and expenses are then not a concern, and not at risk of being cancelled due to a health pandemic. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 the review of fire drill logs, the facility failed to document the amount of time it took for evacuation for the fire drills conducted on November 11, 2019, December 9, 2019, January 9, 2020, February 13, 2020, March 30, 2020, April 24, 2020 and May 26, 2020.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinical Director adjusted the LCOPS Fire Drill Log to include a column for the documentation of the amount of time it takes for all individuals to leave the facility. Prior to this, this column was combined with the "exit used" and was at times, the person conducting the drill forgot to document the time it took to exit the building here. This new documentation format was presented to the staff at the Staff Meeting on 8/6/2020. |