INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 15, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Renewal Treatment Inc., 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 the facility's staffing requirements facility summary report (SRFSR) and a review of personnel records. The facility failed to ensure that all staff persons received 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 in five of thirteen personnel records reviewed.
The findings include:
The facility's SRFSR form completed by the facility on July 11, 2014 was reviewed on July 15, 2014. The form listed five staff as not having completed the mandatory communicable disease training within the regulatory time frames.
Employee # 9, a treatment aide, was hired on March 7, 2011 and was required to obtain 6 hours of HIV/AIDS training by March 7, 2013. The training was not documented as of the date of the inspection.
Employee # 10, a treatment aide, was hired on October 8, 2010 and was required to obtain 6 hours of HIV/AIDS and 4 hours of TB/STD training by October 8, 2012. The training was not documented as of the date of the inspection.
Employee # 11, a treatment aide, was hired on April 2, 2012 and was required to obtain 6 hours of HIV/AIDS and 4 hours of TB/STD training by April 2, 2014. The training was not documented as of the date of the inspection.
Employee # 12, a treatment aide, was hired on August 22, 2011 and was required to obtain 6 hours of HIV/AIDS and 4 hours of TB/STD training by August 22, 2013. The training was not documented as of the date of the inspection.
Employee # 13, a treatment aide, was hired on April 27, 2011 and was required to obtain 6 hours of HIV/AIDS and 4 hours of TB/STD training by April 27, 2013. The training was not documented as of the date of the inspection.
The Facility Director was interviewed on July 15, 2014 confirmed the findings.
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Plan of Correction
Renewal Treatment Inc. shall ensure that all staff persons receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted disease and other health related topics training using a Department approved curriculum. Renewal Treatment, Inc. shall utilize a staff person who has attended this Department approved training to train all of the staff that are in non-compliance using the Department approved curriculum. This training is currently being scheduled. The VP of HR & Compliance shall ensure that this training is scheduled and all non-compliant staff shall take this training. All new hires shall also take this training as part of the orientation This plan of correction is in place. |
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
Based on the review of facility staff CPR/first aid certification cards, the facility failed to provide documentation that at least one person trained in CPR was onsite during the project's hours of operation.
The findings include:
The CPR certification cards were reviewed on July 15, 2014. There was no documentation of CPR coverage for June 1 from 7 AM to 3 PM; June 6 from 4 PM - 11 PM; June 7 from 6 AM to 11 AM; June 13 from 4 PM to 10 PM; June 14 from 7 AM to 3 PM and 11 PM to 7 AM; June 15 from 7 PM to 3 PM; June 28 from 7 AM to 3 PM and July 5 from 7 AM to 2 PM., 2014. The staff covering the times had documentation of a one hour, computer based refresher course. There was no documentation provided that the staff members were currently certified in CPR.
The Facility Director was interviewed on July 15, 2014 and did not dispute the findings.
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Plan of Correction
Renewal Treatment, Inc. shall have staff who are trained in CPR/first aid who have current certification cards onsite during the project's hours of operation. Renewal Treatment, Inc. has in-house CPR, AED and 1st Aid trainers who are approved by the Red Cross. Staff who attend the in-house classes and pass the testing requirements receive certification cards that are good for 2 years. All non-compliant staff shall be scheduled for the Red Cross approved in-house classes. This class is currently being scheduled. The VP HR & Compliance shall ensure that this class is scheduled and all non-compliant staff attend, pass the class and receive their certification cards. All new hires will be scheduled for this class as part of their orientation process. This plan of correction is in place. |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on the physical plant inspection, the facility failed to limit smoking to designated smoking areas.
The findings include:
A physical plant inspection was conducted on July 15, 2014. During the inspection of the 6th floor men's bathroom, there was a very strong odor of cigarette smoke.
The maintenance supervisor was present during the inspection and confirmed the findings.
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Plan of Correction
Renewal Treatment, Inc. shall only allow smoking in designated smoking areas. Renewal Treatment Inc. staff have received instruction on this requirement and the smoking regulations. The Program Director and Clinical Supervisors shall ensure that all staff enforce the smoking regulations by holding violators accountable. All clients will be informed of the smoking regulation during their initial orientation to the facility. Staff shall perform regular security rounds which include the bathrooms being cognizant of smoking regulations and shall hold violators accountable using accepted disciplinary means. This plan of correction is in place. |