INITIAL COMMENTS
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This report is a result of a telephone follow-up inspection regarding the plans of correction for the May 2, 2008 and May 5, 2008 licensure renewal inspection. The follow-up inspection was conducted on December 8, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the telephone follow -up and faxed documentation, New Perspectives at White Deer Run. 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 and a plan of correction is due on January 13, 2009.
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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 upon a review of documentation faxed by the facility on December 8, 2008, a self report by the facility, the facility failed to ensure that one out of three three persons cited during the licensing renewal inspection ending on May 5, 2008 for not having completed the mandatory HIV/AIDS received a minimum of 6 hours of HIV/AIDS training.
Findings:
One out of three persons reviewed failed to complete the required minimum 6 hours of training for HIV/AIDS within the established time frames, specifically # 7.
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Plan of Correction
The staff member in question is a contacted physician who works per diem on an emergency basis. He will receive the training mandatory 6 hour training no later than February 8, 2009 by a certified BDAP trainer. Compliance will be met by facility forwarding a certifcate of attendance dated no later than February 8, 2009 to DAPL. Ongoing compliance will be monitored and followed up for all new personnel, employed or contracted by the Campus Director. |
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 upon a review of staffing schedules and CPR/First Aid certifications faxed on December 8, 2008, the facility failed to ensure that CPR certification and first aid training was be provided to a sufficient number of staff persons, to ensure that
coverage for other than the detoxification unit was provided
Findings:
Based upon a review of staffing schedules and CPR/First Aid certifications faxed on December 8, 2008, the facility failed to ensure that CPR coverage for other than the detoxification unit was provided due to the nurse not being able to leave the detoxification unit and the technician on duty not having a current CPR certification for the dates and hours of operation listed below:.
October 3, 2008 10:00 P.M.-12:00 A.M.
October 4, 2008 10:00 P.M. - 12:00 A.M.
October 11, 2008 10:00 P.M. - 12:00 A.M.
October 17, 2008 10:00 P.M. - 12:00 A.M.
October 18, 2008 10:00 P.M. - 12:00 A.M.
October 24, 2008 10:00 P.M. - 12:00 A.M.
October 25, 2008 10:00 P.M.-12:00 A.M.
October 28, 2008 1:00 P.M. - 2:00 P.M.
November 7, 2008 10:00 P.M. - 12:00 A.M.
November 8, 2008 10:00 P.M. - 12:00 A.M.
November 12, 2008 10:00 P.M. - 12:00 A.M.
November 13, 2008 10:00 P.M. - 12:00 A.M.
November 14, 2008 10:00 P.M. -11:00 P.M.
November 15, 2008 8:00 P.M. - 12:00 A.M.
November 16, 2008 10:00 P.M. - 12:00 A.M.
November 17, 2008 10:00 P.M. - 12:00 A.M.
November 20, 2008 10:00 P.M.-12:00 A.M.
November 22, 2008 10:00 P.M. - 12:00 A.M.
November 29, 2008 8:00 P.M. - 12:00 A.M.
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Plan of Correction
Compliance was met on 12/03/2008 by staff member in question obtaining her re-certification which allowed her to cover her shifts in the rehab unit from that point on. Ongoing compliance will be met by having a facility trained "Trainer" on staff who will provide training to any and all new personnel who require it. This trainer will have been certified no later than January 31, 2009. Ongoing monitoring and compliance will be the responsibility of the Campus Director. |