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 August 14, 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, Project Transition 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 review of personnel records, the facility failed to ensure that each counselor complete at a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis and sexually transmitted diseases training within the first year of employment in one of one applicable records reviewed.
Employee # 5 was hired as a counselor on May 13, 2019 and as of this date of the inspection, the employee had no documentation that the HIV/AIDs training and the TB/STD training were completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The findings were reviewed with the Project Director and Facility Director. Employee #5 did not complete her HIV/AIDS and TB/STD training within her first year of hire. Employee #5 is scheduled in the next TB/STD class on 9/11/20 and the next HIV/AIDS class on 9/25/20. Alerts will be sent to the employees whenever they have training coming due. The Project Director and Clinical Supervisor will ensure that all staff complete their staff development plan and a minimum of 25 training hours during Project Transition's training year during supervision and by using progressive discipline when necessary. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on review of the facility's August 2019 through July 2020 fire drill logs, the facility failed to conduct an unannounced fire drill for the month of April 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The findings were reviewed with the Project Director and Facility Director. Project Transition's physical location was not open during the month of April 2020 due to the COVID-19 pandemic. Project Transition has since opened the office back up and has resumed conducting monthly fire drills. In the future, if an exception is needed, the Quality Department will file an exception with the Department of Drug and Alcohol. The PT Greenbriar Program Director will ensure that fire drills are conducted on a monthly basis. The Director of Residential Programs will review fire drills on a monthly basis to ensure that they are occurring. |