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 10, 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, Diakon Family Life Services 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 a review of six personnel records on August 10, 2020, the facility failed to document the completion of 12 clock hours of annual training required for project directors in employee #1's personnel record.
Employee # 1 was hired as a project director on December 1, 2016 and was still in this position at the time of the inspection. The facility's training year that was reviewed was from January 1, 2019 through December 31, 2019. Employee #1's personnel record documented 0 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.11(d) (2) was reviewed with the Project Director on 5/20/20 noting the required clock hours of annual training. Quarterly monitoring of this regulation will be completed by the Facility Director, with written reminders to staff on the training requirements as well as training feedback. All required annual trainings will be completed by the December 31st deadline. Compliance with this standard will be monitored and enforced by the Facility Director |
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 a review of six personnel records on August 10, 2020, the facility failed to ensure that all employees on all shifts are trained to perform assigned tasks during emergencies.
Employee # 1 was hired as a project director on December 1, 2016 and was still in this position at the time of the inspection. Employee #1 should have been trained for emergencies by December 8, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.28 (d) (3) was reviewed with the Project Director on 8/10/20, as wells as training on how to perform assigned tasks during emergencies. All employees on all shifts will be trained to perform assigned tasks during emergencies. During the orientation process. Compliance with this standard will be monitored and enforced by the Facility Director. |
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 seven fire drill logs conducted on August 10, 2020, the facility failed to maintain a written fire drill record that includes problems encountered and whether the fire alarm or smoke detector was operative.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.28 (d) (4) was reviewed with facility staff on 8/10/20, including the expectation that each month a written fire drill record is completed, including problems encountered and whether the fire alarm or smoke detector is operative. Compliance with this standard will be monitored and enforced by the Facility Director |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of seven fire drill logs conducted on August 10, 2020, the facility failed to prepare alternate exit routes to be used during the drill for six fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.28 (d) (5) was reviewed with facility staff on 8/10/20, including the expectation that each month an unannounced fire drill is completed, using alternate exit routes. Compliance with this standard will be monitored and enforced by the Facility Director. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of six personnel records on August 10, 2020, the facility failed to prepare an annual written individual staff performance evaluation, copies of which shall be reviewed and signed by the employee.
Employee # 1 did not have documentation of an annual work performance evaluation for the 2019 year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.26 (b) (3) was reviewed with the Project Director on 8/10/20, regarding annual written performance evaluations. Performance evaluations will be completed in writing and signed by all employees on an annual basis. Compliance with this standard will be monitored and enforced by the Facility Director. |