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 August 19, 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, Dreamlife 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(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 provide documentation that staff persons received a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD training using a Department approved curriculum in two of two personnel/training records reviewed.
Employee # 5 was hired April 12, 2019 for the position of counselor.
Employee # 6 was hired February 11, 2019 for the position of counselor.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director, Human Resources Coordinator and QA Coordinator have collaborated with the third party training platform used by Dreamlife Recovery to ensure that all applicable staff members receive a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD training using a Department approved curriculum by identifying the training within the platform that does meet all points within the Department approved curriculum. The previous trainings that did not meet the requirements have been removed from the assigned training portals by the Human Resources Coordinator. In addition, the Human Resources Coordinator, Project Director and QA Coordinator have developed a tracking sheet specifically for training that will identify all trainings to be completed by each employee and the required time frames. The training tracking will be analyzed by the Human Resources Coordinator and reported on a monthly basis during the Performance Improvement Committee meetings.
Employee #5 and Employee #6 will take the new assigned courses to complete the 6 hours of HIV/AIDS and 4 hours of TB/STD using a department approved curriculum, by October 3, 2020.
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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 two of two personnel/training records reviewed.
Employee # 3 was hired June 22, 2020. Fire extinguisher training was not documented until July 6, 2020.
Employee # 4 was hired May 25, 2020. Fire extinguisher training was not documented until July 6, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director, Human Resources Coordinator and QA Coordinator have collaborated to correct this deficiency. It was identified that the policies and procedures needed to be revised to reflect this requirement. As a result, policy #HR-2.003 Employee Orientation and HR-2.030 Inservice Education and Training Program have been revised to reflect that the fire safety training will occur no later than 7 days from the date of hire. The Human Resources Coordinator has amended the new hire tracking list as a measure to ensure that the deficiency does not recur and that all employees are trained on the use of fire extinguishers within 7 days of hire. As of August 20, 2020 all new hires have completed the fire safety training within 7 days of the date of hire. The training tracking will be analyzed by the Human Resources Coordinator and reported on a monthly basis during the Performance Improvement Committee meetings. |
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 two of two personnel/training records reviewed.
Employees # 3 and 4 did not have documentation of emergency training upon employment for their assigned shift.
Employee # 3 was hired June 22, 2020. Emergency training was not documented until July 6, 2020.
Employee # 4 was hired May 25, 2020. Emergency training was not documented until July 6, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director, Human Resources Coordinator and QA Coordinator have collaborated to correct this deficiency. It was identified that the policies and procedures needed to be revised to reflect this requirement. As a result, policy #HR-2.003 Employee Orientation and HR-2.030 Inservice Education and Training Program have been revised to reflect that the emergency management plan training will occur no later than 7 days from the date of hire. The Human Resources Coordinator has amended the new hire tracking list as a measure to ensure that the deficiency does not recur and that all employees are trained to perform assigned tasks during emergencies via the emergency management plan within 7 days of hire. As of August 20, 2020 all new hires have completed the emergency management plan training within 7 days of the date of hire. The training tracking will be analyzed by the Human Resources Coordinator and reported on a monthly basis during the Performance Improvement Committee meetings |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The facility failed to document an annual financial audit for the fiscal year ending December 31, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director and QA Coordinator collaborated with the facilities Managing Partners to correct this deficiency. It was identified that the policies and procedures needed to be revised to reflect this requirement. As a result, policy #ORG-1:004 Financial Functions has been revised to reflect the requirement of an annual financial audit conducted by an independent certified public account occur using generally accepted accounting principles. The organization will identify an independent certified public accountant and have an annual financial audit for the fiscal year ending on December 31, 2019 by November 15, 2020. To prevent this deficiency from recurring, the QA Coordinator has added the requirement of an annual financial audit to the Performance Improvement annual workplan, which is analyzed by the QA Coordinator and reported on a monthly basis during the Performance Improvement Committee meetings. |