INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 30, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gratitude House 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 and training records on October 30, 2017, the facility failed to provide documentation of TB/STD training in two of eight applicable records reviewed.Employee #6 was hired on August 20, 2015 as a Behavioral Health Tech and is still in that position. The employee was required to obtain 4 hours of TB/STD training by August 20, 2017. There was no documentation of this training at the time of inspection.Employee #7 was hired on March 5, 2015 as a Behavioral Health Teach and is still in that position. The employee was required to obtain 4 hours of TB/STD training by March 5, 2017. There was no documentation of this training at the time of inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will ensure that employee #6 and employee #7 attend the next scheduled TB/STD training at Pyramid's Corporate Training room, which is scheduled for February 8, 2018. Program Director will follow up with Human Resource Coordinator to ensure attendance. Human Resource Coordinator will monitor employee files quarterly to ensure compliance with mandated trainings. |
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 a review of the facilities staff schedule work hours and the First Aid and CPR certification cards on October 30, 2017, the facility failed to provide a sufficient number of staff persons trained in CPR and First Aid during the project's hours of operation.The Non-Hospital Rehabilitation facility is operable twenty four hours per day/seven days per week.Employee #8 was hired as a Behavioral Health Tech on 9-4-17 and does not have First Aid and CPR certification. Employee #8 was the only staff member working on September 24, 2017, October 1, 2017 and October 7, 2017 from midnight to 8:00 am. The facility failed to have sufficient coverage.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #8 completed his First Aid/CPR training on November 15, 2017. Program Director and BH Tech Supervisor will ensure all staff members are scheduled for First Aid/CPR training within a proper time frame of being hired. BH Tech Supervisor will ensure a minimum of one BH Tech whom is First Aid/CPR trained is scheduled on each shift. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on the review of client records on October 30, 2017, the facility failed to document a complete physical examination as part of the intake procedures in one of eight patient records. Client #8 was admitted on April 17, 2017 and discharged on May 16, 2017. A physical examination was performed on April 18, 2017 but was not complete. The client's vital signs were not documented in the record.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Nurse practitioner will complete physical examinations/vitals as required for all clients entering the Halfway House Program. Program Director will conduct monthly chart audits to ensure compliance. |