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 July 16, 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, Penn Presbyterian Medical Center 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 the personnel records, the facility failed to provide documentation of an individual training plan for one of five employee records reviewed
Employee # 1 was hired as the Project Director on May 17, 2020. There was no documentation of an individual training plan for the current year, which was identified as January 1, 2020 December 31, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: 704.11(b)(1) LICENSURE Individual training plan:
Policy, Procedure, and Forms related to all individual training plans (Introductory Period, Year 1 (1 year 6 month) and following annual reviews were reviewed by Director of Behavioral Health and Project Director/Facility Director as follows:
Specific course of action:
During orientation period as part of the initial orientation to role all staff will complete an introductory training plan as part of their new role.
The deficiency listed in the survey applies to the Director of Behavioral Health. Date the employee listed in the deficiency will have their training plan completed is: 7/28/2020.
Means
Introductory training plan has been added to the "Introductory Checklist" to ensure completion for every staff member.
Person or persons (by job title) responsible for achieving and maintaining compliance with the standard:
Clinical Manager, Nursing Manager & Director of Behavioral Health
The staff member's direct manager is responsible for ensuring adherence to this policy, ensuring checklist is complete including Individual Training Plan.
The introductory period (typically) lasts 6 months at which time an Introductory review occurs and is documented. At that time an individualized training plan is created for the next year (1 year, 6 months from initial hire date) the completion of which the first annual review will be held. Documentation of annual review occurs with updated individual training plan.
Means
1. An individualized training plan has been added for the introductory period of all staff members.
2. The individualized training plan has been added to the Orientation checklist to ensure that it is completed for all new employees to their roles
Methodology for Achieving and Maintaining Compliance:
Individual training plans will be added to monthly compliance check for all employees moving forward to ensure appropriate training plans (Introductory/New Hire, 6-Month, and Annual) are completed as indicated for all employees.
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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 the review of personnel records, the facility failed to document the instruction in the use of fire extinguishers upon employment in one of five personnel records reviewed.
Employee # 2 was hired as a counselor on September 9, 2019. The fire extinguisher and emergency training was not completed until October 2, 2019.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Plan of Correction: 705.28 (c) (4) LICENSURE. Fire safety
Policy, Procedure, and Forms related 705.28 (c) (4) LICENSURE. Fire safety (were reviewed by Director of Behavioral Health and Project Director/Facility Director as follows:
Specific course of action
During the first week of hire as part of the initial orientation to role all staff will complete the course instruction in the use of the fire extinguisher and fire safety.
Means
Fire extinguisher use and fire safety training within first week of hire has been added to the "Introductory Checklist" to ensure completion for every staff member. After the introductory period all staff will complete training annually and as needed.
Person or persons (by job title) responsible for achieving and maintaining compliance with the standard:
Clinical Manager, Nursing Manager & Director of Behavioral Health
The staff member's direct manager is responsible for ensuring adherence to this policy, ensuring checklist is complete including Fire extinguisher use and fire safety training.
Means
1. Fire extinguisher use and fire safety training within first week of hire has been added for the introductory period, first week of hire within the introductory period, for all staff members.
2. The Fire extinguisher use and fire safety training within first week of hire has been added to the Orientation checklist to ensure that it is completed for all new employees to their roles
Methodology for Achieving and
Maintaining Compliance:
Fire extinguisher use and fire safety training within first week of hire as evidenced by completed Knowledge Link training or evidence of unit training will be added to monthly compliance check for all employees moving forward to ensure fire extinguisher use and fire safety training within first week of hire (Introductory/New Hire and Annual) are completed as indicated for all employees. |
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, on all shifts, were trained to perform assigned tasks during emergencies in one of five personnel records reviewed.
Employee # 2 was hired as a counselor on September 9, 2019. The fire extinguisher and emergency training was not completed until October 2, 2019.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Plan of Correction: 705.28 (c) (4) LICENSURE. Fire safety
Policy, Procedure, and Forms related 705.28 (c) (4) LICENSURE. Fire safety (were reviewed by Director of Behavioral Health and Project Director/Facility Director as follows:
Specific course of action
During the first week of hire as part of the initial orientation to role all staff will complete the course instruction in the use of the fire extinguisher and fire safety.
Means
Fire extinguisher use and fire safety training within first week of hire has been added to the "Introductory Checklist" to ensure completion for every staff member. After the introductory period all staff will complete training annually and as needed.
Person or persons (by job title) responsible for achieving and maintaining compliance with the standard:
Clinical Manager, Nursing Manager & Director of Behavioral Health
The staff member's direct manager is responsible for ensuring adherence to this policy, ensuring checklist is complete including Fire extinguisher use and fire safety training.
Means
1. Fire extinguisher use and fire safety training within first week of hire has been added for the introductory period, first week of hire within the introductory period, for all staff members.
2. The Fire extinguisher use and fire safety training within first week of hire has been added to the Orientation checklist to ensure that it is completed for all new employees to their roles
Methodology for Achieving and
Maintaining Compliance:
Fire extinguisher use and fire safety training within first week of hire as evidenced by completed Knowledge Link training or evidence of unit training will be added to monthly compliance check for all employees moving forward to ensure fire extinguisher use and fire safety training within first week of hire (Introductory/New Hire and Annual) are completed as indicated for all employees. |