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 May 22, 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, The Highland House, 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
The facility failed to document HIV/AIDS and TB/STD training in one of two personnel/training records reviewed.
Employee # 3 was hired for the position of counselor on April 30, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will ensure that all staff receive HIV/AIDS and TB/STD trainings within the required time frame by providing staff with a checklist of required trainings that need to be completed and a deadline for completion. The clinical supervisor will monitor these checklists on a quarterly basis. Employee # 3 will receive the required trainings no later than July 31, 2020 |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to document fire extinguisher training upon staff employment in four of four personnel/training records reviewed.
Employee # 4 was hired November 1, 2019.
Employee # 5 was hired July 22, 2019.
Employee # 6 was hired November 11, 2019.
Employee # 7 was hired February 24, 2020.
The findings were reviewed with facility during the licensing process.
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Plan of Correction
The clinical supervisor or house manager will provide fire extinguisher safety training and document that training with Employees #4, 5, 6, and 7 by June 12, 2020. Going forward, fire extinguisher training will be part of the new hire's initial training plan and will be completed within the first 7 days of employment, documented by the trainer and new hire, and a signed copy sent to the Executive Director to become part of the employee's personnel file. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to document an unannounced fire drill for October 2019 based on a review of July 2019 - May 2020 fire drill records.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The House Manager will ensure that an unannounced fire drill is conducted and documented every month. A copy of the fire drill report will be sent to the clinical supervisor within 3 working days of the drill. The clinical supervisor will monitor the completion of the drills and will contact the house manager as an intervention measure if the report is not received by the 25th of the month. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
The facility failed to document that all personnel on all shifts were trained to perform assigned tasks during emergencies in four of four personnel/training records reviewed.
Employees # 4, 5, 6 and 7 did not have documentation of emergency training upon employment for their assigned shift.
Employee # 4 was hired November 1, 2019.
Employee # 5 was hired July 22, 2019.
Employee # 6 was hired November 11, 2019.
Employee # 7 was hired February 24, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor or house manager will provide safety training including staff responsibilities and assigned tasks in the case of an emergency, and document that training with Employees #4, 5, 6, and 7 by June 12, 2020. Going forward, emergency training will be part of the new hire's initial training plan and will be completed within the first 7 days of employment, documented by the trainer and new hire, and a signed copy sent to the Executive Director to become part of the employee's personnel file. |