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 2, 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, Resources for Human Development 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on the review of personnel records, the facility failed to ensure that the facility director completed at least 12 clock hours of training during the facility's July 1, 2018 through June 30, 2019 training year.
Employee #2 was hired as the facility director on September 8, 2017. The personnel record documented 10.25 hours of training.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
-Facility director will attend training annually to satisfy training hour requirements.
-Facility director will provide quarterly updates in supervision to direct supervisor regarding completed training hours to ensure deficiency does not occur again.
-Facility director is responsible for monitoring training hours for all staff.
-To date, facility director has satisfied training hours for training year July 1, 2019 through June 30, 2020. |
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 a review of the July 2019 through April 2020 fire drill logs, the facility failed to document, on the August 2019 log, the amount of time it took for evacuation during the fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
-Clinical supervisor will review each fire drill log sheet mid-month to ensure all required information is listed on the fire drill log sheet.
-If information is not listed, clinical supervisor will conduct an additional drill for the month.
-Facility director will review the log on the 25th of each month to ensure that all information is listed on the fire drill log sheet as an additional check.
-If information is not listed, facility director will conduct an additional drill for the month.
-This process will be implemented immediately beginning with June 2020. |