INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 7, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of 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 personnel records, the facility failed to document that each employee completed TB/STD and/or HIV/AIDS training within the required timeframes in nine of eighteen records.
Staff #1 was hired as the project director on September 17, 2018. TB/STD and HIV/AIDS training was due to be completed by September 17, 2020. There was no documentation of HIV/AIDS or TB/STD training in staff record #1.
Staff #3 was hired as a counselor on June 17, 2019 and promoted to clinical supervisor on January 17, 2021. TB/STD and HIV/AIDS training was due to be completed by June 17, 2020. There was no documentation of TB/STD training in staff record #3.
Staff #12 was hired as a counselor on June 17, 2019. TB/STD and HIV/AIDS training was due to be completed by June 17, 2020. There was no documentation of TB/STD training in staff record #12.
Staff #13 was hired as a counselor on January 21, 2020. TB/STD and HIV/AIDS training was due to be completed by January 21, 2021. There was no documentation of TB/STD or HIV/AIDS training in staff record #13.
Staff #14 was hired as a counselor on December 9, 2019. TB/STD and HIV/AIDS training was due to be completed by December 9, 2020. There was no documentation of TB/STD training in staff record #14.
Staff #15 was hired as an aide on March 8, 2019. TB/STD and HIV/AIDS training was due to be completed by March 8, 2021. There was no documentation of TB/STD or HIV/AIDS training in staff record #15.
Staff #16 was hired as an aide on October 7, 2013. TB/STD and HIV/AIDS training was due to be completed by October 7, 2015. There was no documentation of TB/STD or HIV/AIDS training in staff record #16.
Staff #17 was hired as an aide on June 3, 2019. TB/STD and HIV/AIDS training was due to be completed by June 3, 2021. There was no documentation of TB/STD or HIV/AIDS training in staff record #17.
Staff #18 was hired as an aide on November 26, 2016. TB/STD and HIV/AIDS training was due to be completed by November 26, 2018. There was no documentation of TB/STD or HIV/AIDS training in staff record #18.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 6, 2021 licensing inspection.
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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 training 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 or contracted external trainer who has attended this Department approved training to train all of our out of compliance staff using the Department approved curriculum. This training is currently being scheduled and will be completed by 12/31/2021. New hires will have HIV/AIDS and STD/TB scheduled as part of their new hire orientation and during the completion of their new hire training needs assessment. All staff will have their training records audited by their supervisor 2 times a year during the employee evaluation process. The training record audit will include ensure that all staff have taken this required training. Staff that have not completed their required training will have it scheduled at the time ensuring compliance with necessary time frames. Additionally, the VP HR and Compliance shall ensure that the in-house HIV/AIDS (6 hrs.) and STD/TB (4 hrs.) training are scheduled and all non-compliant staff shall be scheduled for this training. The VP HR and Compliance shall have oversight responsibility for this plan of action. This plan of correction is in place. |
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 fire drill records, the facility failed to maintain a fire drill record which included the exit route used.
Fire drills were reviewed for the time period of August 2020 - August 2021. The fire drills conducted in the months of June, March, February and January 2021 as well as December and October 2020 did not include documentation of the exit route used.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal, Treatment Inc. shall maintain monthly fire drill records that record which exit route is used. The security staff performing the headcount shall document the exit route being used on the fire drill form for every monthly fire drill. The Security Supervisory staff shall ensure that the exit route is marked each time a fire drill is performed and subsequently documented. All fire drills that are completed will be emailed to the VP HR and Compliance who shall ensure that the exit route is marked on every fire drill report. The VP HR and Compliance shall be responsible for this plan of action. This plan of correction is in place. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of client records and administrative documentation, the facility failed to document that DDAP was notified of an event at the facility requiring ambulance personnel.
During a client record review, documentation was seen that a client was in need of emergency medical services on April 25, 2021. An ambulance reported to the facility and the client was transported to the hospital. There was no documentation that an unusual incident report was sent to DDAP within three business days following this incident.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 7, 2021 licensing inspection.
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Plan of Correction
Renewal Treatment, Inc. shall file a written unusual incident report within three (3) business days following an unusual incident involving emergency medical services. Renewal Treatment, Inc.'s Clinical Director and VP Program Management/ Project Director shall ensure that an Unusual Incident Reporting Form is completed and filed with the department for all incidents of emergency medical services. The Clinical Director and VP Program Management/Project Director reviewed the requirements for unusual incident reporting and will have overall oversight responsibilities for this plan of action. Additionally, the Clinical Director provided instruction and training to the Clinical Supervisors on this reporting requirement. The Clinical Supervisors shall report all incidents of emergency medical response as well as all other unusual incidents to the Clinical Director and VP Program Management/Project Director who will have reporting responsibilities. This plan of correction is in place. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates at least every 30 days in two of five client records.
Client #1 was admitted on May 12, 2021 and discharged on July 12, 2021. The preliminary treatment plan was completed on May 12, 2021. There were no treatment plan updates documented in client record #1.
Client #3 was admitted on March 3, 2021 and discharged on May 5, 2021. The preliminary treatment plan was completed on March 4, 2021. There were no treatment plan updates documented in client record #3.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. treatment staff shall complete treatment plan updates at least every 30 days. The Clinical Supervisors provided training and instruction to the treatment staff on this requirement and shall ensure compliance via regular documents file audits. The Clinical Director and Clinical Supervisors shall ensure compliance with this plan of correction. This plan of correction is in place. |