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. 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. 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 5, 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, White Deer Run, 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:
|
Plan of Correction
|
Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form on May 5, 2020, the facility failed to ensure that employee #18 received the minimum of 6 hours of HIV/AIDS training within the regulatory timeframe.Employee #18 was hired as a counselor assistant on May 1, 2019 and was due to have the communicable disease trainings no later than May 1, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training.These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Employee #8 was registered to attend HIV/AIDS training on several occasions however due to trainings being cancelled, illness and recently COVID-19 restrictions was noncompliant with meeting this regulation. She will have received this training by 6/30/20
Infection Control Nurse and QI Coordinator will track employee's communicable disease training and alert staff who is still in need of trainings prior to the trainings being offered to ensure staff attendance and compliance with regulation. Tracking sheet will be sent to facility managers/leadership monthly to ensure they are aware who is still in need of training.
Infection control nurse and Human resource department has added HIV/AIDS and TB/STD training to monthly new hire orientation on 1/1/20. All new staff are required to attend new hire orientation. Facility leadership will register at least 5 staff in addition to the new hires in attendance to attend one and/or both of these trainings until all staff hired prior to 1/1/20 have received the trainings.
Failure to attend training within required timeframe will result in disciplinary action.
|