INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 7-8, 2018, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-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:
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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 facility records conducted during the on-site inspection, and based on staff interviews conducted during the on-site inspection, the facility failed to ensure that all of its staff had the required training in communicable diseases. Staff Person #23 was hired a support staff person on 10/29/2015, and was due to have 6 hours of HIV/AIDS training, and 4 hours of TB/STD training by 10/29/2017, but the staff person had not documented training in HIV/AIDS or TB/STD training at the time of the on-site inspection. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Staff person #23 will attend HIV/AIDS training on 6/21/18 and TB/STD training on 6/5/18. Staff person #23 will submit training certificate and evaluation to clinical supervisor and QI department.
QI will send out bi-weekly tracking of staff training, including required trainings. Clinical supervisor will monitor tracking list to ensure staff compliance with state required trainings within regulatory timeframes.
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the physical plant inspection conducted on 05/08/2018, the facility failed to ensure privacy during counseling sessions. During the physical plant inspection there was an individual counseling session being conducted in room 8-7. The door of room 8-7 was open, and the counseling session could be heard from outside of the room. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Clinical Director reviewed regulation 705.4 with all clinical staff during shift report meeting on 5/9/18.
Clinical Director/Ast Clinical Director will review/train new staff during monthly new hire orientation on regulation 705.4.
Clinical supervisors will conduct bi-weekly spot checks to ensure clinical staff are complying with regulatory standard of 705.4 for 6 months. Noncompliance will be addressed during staff supervision/competencies.
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705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on the physical plant inspection conducted on 05/08/2018, the facility failed to ensure that it did not store food on the floor. There were 4 cases of milk stacked 2 by 2 stored on the floor of the walk in refrigerator located in the dry storage area. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Upon delivery food will be stacked on shelving per regulation 705.7.
Dietary staff will be educated on regulation 705.7 and the importance of proper food storage.
Dietary manager will conduct random checks for compliance within all of the food storage areas.
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