INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 26, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gage House, LP 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)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the facility staff schedule for the month of April 2021 and employees with CPR certification and first aid training, the facility failed ensure a sufficient number of staff persons trained in these skills is onsite during the project's hours of operation. April 1, 2021 did not have sufficient coverage from the hours of 7 am-8 am.April 2, 2021 did not have sufficient coverage from the hours of 7 am-8 am.April 3, 2021 did not have sufficient coverage from the hours of 3 pm-12 am.April 4, 2021 did not have sufficient coverage from the hours of 12 am-7 am and 3 pm- 11 pm.April 5, 2021 did not have sufficient coverage from the hours of 7 pm-12 am.April 6, 2021 did not have sufficient coverage from the hours of 12 am-7 am and 8 pm- 11 pm.April 7, 2021 did not have sufficient coverage from the hours of 5 pm-11 pm.April 9, 2021 did not have sufficient coverage from the hours of 7 am-11 pm.April 10, 2021 did not have sufficient coverage from the hours of 7 am-11 pm.April 11, 2021 did not have sufficient coverage from the hours of 3 pm- 12 am.April 12, 2021 did not have sufficient coverage from the hours of 12 am-8 am and 5 pm-11 pm.April 13, 2021 did not have sufficient coverage from the hours of 8 pm-11 pm.April 14, 2021 did not have sufficient coverage from the hours of 5 pm-11 pm.April 16, 2021 did not have sufficient coverage from the hours of 7 am-8 am and 4 pm-11 pm.April 17, 2021 did not have sufficient coverage from the hours of 3 pm-12 am.April 18, 2021 did not have sufficient coverage from the hours of 12 am-7 am and 7 pm- 11 pm.April 19, 2021 did not have sufficient coverage from the hours of 7 pm-11 pm.April 21, 2021 did not have sufficient coverage from the hours of 9 pm-11 pm.April 23, 2021 did not have sufficient coverage from the hours of 7 am-8 am and 7 pm- 12 am.April 24, 2021 did not have sufficient coverage from the hours of 12 am-7 am and 3 pm- 11 pm.April 26, 2021 did not have sufficient coverage from the hours of 5 pm-11 pm.April 27, 2021 did not have sufficient coverage from the hours of 8 pm-11 pm.April 30, 2021 did not have sufficient coverage from the hours of 7 am-8 am and 4 pm- 10 pm.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Agency was unable to facilitate in-person training for CPR during the past year due to COVID restrictions. The trainer who the Agency utilized was contracted through another company, which placed restrictions on in-person classroom trainings during the pandemic. This affected six existing staff in this program, as well as five new staff hired in this program over the past year. The Agency has been able to contract with a new company to facilitate these classroom trainings for us, and they have begun in June, 2021.
Two of these identified eleven staff have completed the CPR classroom training in early June 2021. Four of these identified staff are scheduled to complete the CPR classroom training in late June 2021. The remaining five staff are scheduled to complete the CPR classroom training in July 2021.
When staff scheduling for the program is developed and planned during this identified training time, care is taken to ensure staff are scheduled to each shift who are CPR certified. This attention to detail in the scheduling process will take place during the month of June and July, until all staff have been recertified in CPR. The program manager will be responsible for the schedule creation and ensuring that all shifts are covered by CPR certified staff. The clinical supervisor will monitor the scheduling process.
The Human Resources Specialist will schedule and monitor completion of the required training. Each individual employee (Residential aide, Nurse, counselor) is responsible for attending the scheduled training to complete the requirement and maintain compliance.
The Agency will be in full compliance with this standard by August 1, 2021.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on one of four applicable personnel records reviewed, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment and provide documentation.Employee # 1 was hired as the project/facility director on February 13, 2021 and was still in this position at the time of the inspection. There was no documentation of staff being instructed in the use of fire extinguishers in the employee record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Safety training was completed by the identified employee (#1) on June 17, 2021, utilizing the on-line training system Relias.
The Project / Facility Director is responsible for achieving compliance with this standard. The Director of Risk Management will monitor completion of the required training.
The Agency is in full compliance with this standard as of June 17, 2021. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on one of four applicable personnel records reviewed, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.Employee # 1 was hired as the project/facility director on February 13, 2021 and was still in this position at the time of the inspection. There was no documentation of emergency training in the employee record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Workplace Emergency training was completed by the identified employee (#1) on June 22, 2021, utilizing the on-line training system Relias.
The Project / Facility Director is responsible for achieving compliance with this standard. The Director of Risk Management will monitor completion of the required training.
The Agency is in full compliance with this standard as of June 22, 2021.
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709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
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Observations
Based on eight of eight client records reviewed, the facility failed to provide documentation during client orientation to include the fee schedule in client record #'s 1-8.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An additional section was added to the Residential Consents service entry in the electronic health record (EHR) to indicate that the client was provided information related to the fee schedule for treatment to be provided at the facility. Response by the client in this documentation will be indicated as agree: yes or no. The form edit was completed in the EHR service entry form (Residential Consents) on June 24, 2021 by the EHR System Specialist. All clinical staff will receive training and notification of this process during the weekly staff meeting to be held on June 29, 2021 The Clinical Supervisor and Program Manager will review this process with staff again as needed to ensure understanding of the process.
The fee schedule has been added as content to the client handbook. The handbook and the fee schedule information will be discussed with clients upon admission to the facility during program orientation which is completed by the Counselor, Counselor Assistant, Program Manager, or Clinical Supervisor. At the time this information is discussed with the client, the staff person will document client's response within the Residential Consents document in the EHR. All clients being admitted to the facility after June 29, 2021 will have this information documented in their record. The Clinical Supervisor is responsible for oversight of the full process and compliance with the standard.
The Clinical Supervisor, Program Manager, and Director of Risk Management will monitor completion of this process and monitor compliance with this standard.
The Agency will be in full compliance with this standard beginning June 29, 2021.
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