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 1, 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, Peace Valley Recovery LLC. 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of personnel records, the facility failed to complete individual training plans within the expected timeframe outlined by Licensing Alert 03-2005, which states the initial training plan of newly hired employees will be completed within 30 days from the date of hire in four of seven employee records reviewed.
Employee #1 was hired on August 15, 2019, the individual training plan was completed on October 21, 2019.
Employee #3 was hired on November 13, 2019, the individual training plan was completed on May 18, 2020.
Employee #4 was hired on March 16, 2020, the individual training plan was completed on May 21, 2020.
Employee #6 was hired on October 28, 2019, the individual training plan was completed on May 26, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PVR will create an individual training plan for all employees, regardless of status within 30 days from the date of hire, moving forward (starting in June 2020).The Facility Director will meet with each new hire within 15 days of hire to review individual training plan. |
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 the review of personnel records, the facility failed to instruct all staff, upon employment, in the use of fire extinguishers in four of seven employee records reviewed.
Employee #1 was hired on August 13, 2019, the fire extinguisher training was provided on October 21, 2020.
Employee #3 was hired on November 13, 2019, the fire extinguisher training was provided on May 19, 2020.
Employee #5 was hired on April 29, 2020, the fire extinguisher training was provided on May 21, 2020.
Employee #7 was hired on January 9, 2020, the fire extinguisher training was provided on May 12, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PVR will conduct the fire extinguisher trainings during day 1 of orientation (the facility tour) and it will remain documented in the Employee Handbook receipt page. The Facility Director will ensure that the Safety Officer trains each new hire on fire safety during day 1 of orientation. This will be competed for all new hires beginning in the month of June 2020. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on the review of the October 2019 through April 2020 fire drill log, the facility failed to conduct fire drills that were unannounced in November 2019, December 2019, January 2020, and April 2020. Additionally, the facility failed to conduct a fire drill during the month of October 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PVR will continue to conduct fire drills but moving forward the monthly drills will be unannounced. Some months the Facility Director will ensure that the Safety Officer is staging additional announced fire drills as well. The unannounced drills will begin in the month of June 2020. |
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 the review of personnel records, the facility failed to ensure that all personnel are trained to perform assigned tasks during emergencies in four of seven employee records reviewed.
Employee #1 was hired on August 13, 2019, the emergency preparedness training was provided on October 21, 2020.
Employee #3 was hired on November 13, 2019, the emergency preparedness training was provided on May 19, 2020
Employee #5 was hired on April 29, 2020, the emergency preparedness training was provided on May 21, 2020
Employee #7 was hired on January 9, 2020, the emergency preparedness training was provided on May 12, 2020
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PVR will continue to train all employees on emergency preparedness but this will be included in day 1 of orientation. Beginning in the month of June 2020 the Facility Director will ensure that the Safety Officer trains all new employees in emergency preparedness on day 1 of their orientation. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on the review of the November 2019 through April 2020 fire drill log, the facility failed to identify on the fire drill log, the time of the drill, the amount of time it took for evacuation, the exit route used, the number of persons in the facility, and whether the fire alarm or smoke detector was operative during conducted drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PVR Facility Director will create a new fire drill log with the Safety Officer. All appropriate changes were made and implemented into the new log to capture all required content. This new log will be implemented in the month of June 2020. Facility Director will confirm that this log is being utilized monthly beginning in June 2020 for both announced and unannounced fire drills. |