INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 28 - 29, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Summit 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
Twenty-one personnel records were reviewed on September 28-29, 2016. The facility failed to provide documentation of TB/STD training in one personal record.
Employee #19, a counselor, was hired May 28, 2015. HIV/AIDS and TB/STD training was due to be completed no later than May 28, 2016. Employee #19 completed TB/STD on September 16, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff member in question completed training, but did so outside the required time frame. Summit Academy will ensure this standard is met moving forward by creating a training registration memo to the Clinical Coordinator two weeks prior to the training date. Attendance will be verified by the Clinical Coordinator, who will forward that information to the HR Coordinator. The Clinical Coordinator and Human Resources Coordinator will implement this new system as of 10/27/16. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of administrative documents pertain to the facility's unusal incident policy, on September 28-29, 2016, the facility failed to notify the Department within 3 business days following the occurrence of an unusual incident.
The police was called to the facility on two seperate occasions 10/13/15 and 1/10/16.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Summit Academy's Critical Incident and Unusual Incidents Policy indicates that DDAP is to be notified within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel. The Program Director is responsible for notifying licensing entities regarding unusual incidents. He was retrained regarding the specifics of the policy on 09/29/16. In order to ensure compliance, the Program Director will provide a copy of the incident reports sent to DDAP to the Project Director for review. |