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.
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 June 29, 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, Gratitude House 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 a review of six personnel records, the facility failed to provide documentation of one staff person receiving a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training within the first 2 years of employment.
Employee # 6 was hired as a housekeeper on April 30, 2018 and was still in this position at the time of the inspection. There was no documentation of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training which was due on April 30, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will ensure that employee #6 attend the next scheduled TB/STD training at Pyramid's Corporate Training room, once the updated training calendar is available. Program Director will follow up with Human Resource Coordinator to ensure attendance. Human Resource Coordinator will monitor employee files quarterly to ensure compliance with mandated trainings. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility fire drill log between January 2019 and May 2020, the facility failed to provide documentation of alternate exit routes being used during fire drills.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from August 2019.
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Plan of Correction
Maintenance Director reviewed fire drill regulations/policy with staff on 6/29/2020. Addressed utilization of alternative exit routes when conducting monthly drills. Program Director and Maintenance Supervisor will monitor monthly fire drill logs to ensure compliance. |