INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on June 13-14, 2019. Based on the findings of the on-site inspection, Colonial House, Inc. was found to not 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)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The facility shall provide CPR certification and first aid training to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
The facility failed to have staff trained in CPR and first aid on the following days and hours:
May 19, 2019 from 3-4pm and from 10-11pm
May 22, 2019 from 3-11pm
May 28, 2019 from 3-4pm and from 10-11pm
June 4, 2019 from 9-11pm
June 11, 2019 from 9-11pm
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CPR/First Aid training has been scheduled to take place 8/16/2019. All current employees who are not CPR/First Aid trained and new hires since on-site licensure renewal inspection will be trained at this time.
The Director of Operations will review staffing schedules submitted by Night Tech Supervisor to ensure that all working shifts are covered by at least one person who is CPR/Frist Aid trained. A person who is not CPR/First Aid certified will not be permitted to work by themselves until they receive the appropriate training.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
The facility failed to ensure that each counselor completed at least 25 clock hours of training annually.
Staff #5 was hired on October 10, 2017 as a counselor. Staff #5 had 20 hours of documented training for the training year July 1, 2017 through June 30, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Operations will monitor employee training hours on a quarterly basis to ensure annual compliance associated with required training hours. The quarterly reviews will take place 10/2019, 1/2020, 4/2020. All employee training certificates be submitted to the Director of Operations for compliance monitoring purposes. These certificates will be maintained and hours will be tallied in the employee training record. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
The facility failed to have a policy in place to address that disinfectants and drugs for external use are stored separately from oral and injectable drugs.
There was no documented policy addressing that disinfectants and drugs for external use are stored separately from oral and injectable drugs in the Policy and Procedure manual.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Quarterly medication reviews are completed by the Night Tech Supervisor. During these reviews, compliance with the regulation associated with "disinfectants and drugs for external use are stored separately from oral and injectable drug" is monitored however; there failed to be a written policy addressing this specific issue.
The medication administration policy was updated on 7/16/2019 by the Executive Director to include that disinfectants and drugs for external use are stored separately from oral and injectable drugs. As all client's medications are kept in a zip-lock bag with the person's name on it in the top drawer of the medication cart, disinfectants and drugs for external use are kept in the second drawer of the medication cart. |