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.
Part 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.
Part 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 May 18, 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, Silver Pines Treatment Center 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
The facility failed to ensure staff persons 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.
Staff #3 was hired as a counselor assistant on December 17, 2018 and then promoted to counselor on December 2, 2019. Staff #3 did not receive the HIV/AIDS training.
Staff #5 was hired on April 23, 2018 as a Care Coordinator. Staff #5 did not receive the HIV/AIDS and the TB/STD trainings.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff must have completed the necessary trainings within the required time frame.
Employee #3 will complete their HIV/AIDS training by 6/19/20.
Employee #5 will complete their HIV/AIDS training by 6/19/20. Due to COVID-19 restrictions and lack of trainings online, employee will complete their TB/STD training by 10/1/20.
Moving forward Director of Quality Assurance will be auditing training on a quarterly basis and ensuring that staff is scheduled for these trainings before the mandatory time frame elapses.
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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 twelve fire drills from May 2019 through April 2020, the facility failed to maintain a written fire drill record to include the exit route used and whether the fire alarm or smoke detector was operative.
All fire drills from May 2019 through April 2020 were missing the exit route used during the fire drill.
All fire drills from May 2019 through April 2020 were missing whether the fire alarm or smoke detector were operative during the fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill form has been updated on 5/26/20 to include the exit route and an option to mark that a smoke detector/fire alarm were operative during the drill. Staff will be trained on this updated form on 5/29/20. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of twelve fire drills from May 2019 through April 2020, the facility failed to document if a fire alarm or smoke detector was set off during each fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill form has been updated on 5/26/20 to include an option to mark that the fire alarm was set off during each drill. Staff will be trained on this updated form on 5/29/20. |