INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 9-10, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Snug Harbor Rehabilitation and 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:
|
Plan of Correction
|
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
|
Observations
Based on a review of personnel records, the facility failed to ensure a mechanism was used to collect feedback on completed training during the 2023-2024 training year in two of two applicable records. Staff #1 was hired on June 8, 2020 and still a current employee. Staff #1 did not complete feedback forms on completed trainings for the 2023- 2024 training year except for 1 hour of in-house training.Staff #3 was hired on February 27, 2023 and still a current employee. Staff #3 did not complete feedback forms on completed trainings for the 2023- 2024 training year except for 2 hours of in-house training.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
We have updated our evaluation process to include all trainings rather than just those trainings done in house.
All staff has been educated on this process and will begin evaluating all trainings as of January 2, 2025.
Program Director will ensure this new process occurs. |
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure employees received the minimum of at least 4 hours of TB/STD and other health related topics within the first year of employment in one of one records. Staff #3 was hired as a counselor on February 27, 2023 and still employed at the time of the inspection. Approved TB/STD training was due to be completed by February 27, 2024 but was not completed until October 8, 2024. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the March 23, 2023 and the December 7, 2023 licensing renewal inspections.
|
Plan of Correction
We have re-educated our current staff as well as implemented a check mechanism for new hires to ensure Communicable Disease trainings are completed within the first 2 years of their employment for support staffing, and in the first year for counselors and assistant counselors.
Program Director will ensure this process is adhered to and maintained.
This will be effective 1/2/25 |
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.
|
Observations
Based on a review of administrative information, the facility failed to ensure CPR certification and first aid training was 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 operations in the residential treatment activity. Reviewed staff schedules from November 1 through November 30, 2024. The following dates and times did not have staff people who were CPR certified or trained in first aid in residential treatment:All day on November 1 and 2. November 3 from 12 am to 7 am and again from 3 pm to 11:59 pm. November 4, 5, 6, and 7 from 12 am to 7 am and again from 5 pm to 11:59 pm. November 8 from 12 am to 9 am and again from 5 pm to 11:59 pm. All day on November 9.November 10 from 12 am to 7 am and again from 3 pm to 11:59 pm. November 11, 12, 13, and 14 from 12 am to 7 am and again from 5 pm to 11:59 pm. November 15 from 12 am to 9 am and again from 5 pm to 11:59 pm. All day on November 16.November 17 from 12 am to 7 am and again from 3 pm to 11:59 pm. November 18, 19, 20, and 21 from 12 am to 7 am and again from 5 pm to 11:59 pm. November 22 from 12 am to 9 am and again from 5 pm to 11:59 pm. All day on November 23.November 24 from 12 am to 7 am and again from 3 pm to 11:59 pm. November 25, 26, and 27 from 12 am to 7 am and again from 5 pm to 11:59 pm. November 28 from 12 am to 7 am and again from 2 pm to 11:59 pm. November 29 from 12 am to 9 am and again from 5 pm to 11:59 pm. All day on November 30.This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Residential Staff will be encouraged to renew their certification for CPR and maintain current status at all times. In addition, we will provide information on available training opportunities ensuring there is CPR certified individuals in residential at all times. This action will be completed in January of 25.
This will be monitored by the Program Director and effective 1/25. |
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.
|
Observations
Based on a review of fire drill records and staff interviews, the facility failed to conduct monthly fire drills. The fire drills were reviewed for the period of December 2023 to November 2024. Fire drills at the residential building were not conducted during the months of February, June, July and September 2024. Fire drills at the detox building were not conducted during the months of December 2023, January, March, April, May, August, October and November 2024.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Property Manager has been re-educated on the process of fire drills. He will ensure both detox and residential drills will take place at the same time and date.
We have updated our form to reflect this procedure and to serve as a reminder that the process cannot be completed unless drills are conducted in both buildings at the same date and have been recorded.
This will be in effect 1/2/25 and will be monitored by the Property Manager. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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.
|
Observations
Based on a review of fire drill records, the facility failed to maintain a fire drill record which included all the required components. The fire drills were reviewed for the period of December 2023 to November 2024. March and May 2024 did not include number of persons evacuated during the fire drills. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
We have revised our document recording fire drills to include the component of a number of evacuees rather than the names of individuals. This modification has been completed as of 12/10/24/.
The new process will be in effect 1/2/25 and will be monitored by the Property Manager.
|
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
|
Observations
Based on a review of client records, the facility failed to document a purpose of disclosure on the release of information form in one of fourteen client records.Client #3 was admitted November 7, 2024 and still a current client. A release of information to an individual contact was signed by the client on November 17, 2024 but did not indicate the purpose of disclosure. This finding was reviewed with the facility staff during the licensing process. This is a repeat citation from the December 7, 2023 licensing inspection.
|
Plan of Correction
A training is scheduled after the first of the year for a clinical staff to re-educate them on the proper way to complete an ROI.
They will be educated on the importance of clearly stating a purpose for the ROI.
This will be conducted by the program Manager and Executive Director.
This will be effective 1/2/25
and the Program Director through random audits will ensure this is maintained. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for mandatory communicable disease training was submitted and approved by the Department for the March 23, 2023 and December 7, 2023 annual licensing inspections. Communicable disease trainings were again found to be a deficiency in the December 10, 2024 licensing inspection. These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Both Program Director and Executive Director will work diligently to adhere to our POC.
Trainings will be held to re-enforce the proper way to document.
A clear discussion with all employees takes place after the survey is completed. The POC is clearly discussed and will be enforced to the best of our ability through re-education of any and all deficiencies.
This will be in effect by 1/2/25
and will be closely monitored by the Program Director through random audits and chart reviews.
|