INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 9, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Outlook Academy 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 the review of personnel /training records, the facility failed to ensure staff persons received the required HIV/AIDS and/or STD/TB training within the required timeframes in
one of one applicable record reviewed.
Employee # 11 was hired as a counselor assistant on November 2, 2020. HIV/AIDS and STD/TB training was to be completed by November 2, 2021. There was no documentation the training had been completed as of the inspection date.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
New Outlook Academy will continue to monitor for DDAP approved virtual trainings on HIV/AIDS and tuberculosis, sexually transmitted diseases and other health related topics in order to have employees participate within the required timeframes. In the event no virtual trainings are available within the counselor or counselor assistant's initial year of employment, New Outlook Academy will utilize in-house medical personnel to complete this training with DDAP approved curriculum. New Outlook Academy anticipates having all staff who are currently past their required timeframes complete these trainings by May 1, 2022. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the client records, the facility failed to document written acknowledgement by clients they have been notified of all of their rights. The written acknowledgement was missing (2), The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
Seven of seven client records reviewed failed to document written acknowledgement by clients they have been notified of this right.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
New Outlook Academy is in the process of updating the client rights document to include notification that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, national origin, marital status, sexual orientation, handicap, or religion. New Outlook Academy will begin using this document for all new admissions and will review this document with all current clients to inform them of their rights as soon as the form is finalized. We anticipate the new form will be signed by all clients no later than March 31, 2022. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of the administrative information, the facility failed to document monthly inspections of the storage areas. The facility policy states monthly inspections will be conducted.
Documentation of the inspections were reviewed from November 2020 to current. Inspections were not documented for December 2021, January 2022, and February 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The New Outlook Academy medical department will document reviews on a monthly basis of drug storage areas to ensure compliance with State and Federal laws. During quarterly compliance checks, the quality assurance department will review the documented inspections to ensure these are being completed as scheduled. The first quarterly compliance review including this will be in June of 2022. |