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 14, 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, Renewal Treatment, Inc 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 of HIV/AIDS and/or TB/STD training in six of six personnel records.
Employee # 4 was hired as a counselor on April 16, 2018 and promoted to a supervisor on May 20, 2019. The STD/TB training was to be completed by April 16, 2019. There was no documentation the training had been completed.
Employee # 5 was hired as a counselor on June 17, 2019. The HIV/AIDS and STD/TB training was to be completed by June 17, 2020. There was no documentation the training had been completed.
Employee # 6 was hired as a counselor on May 7, 2019. The STD/TB training was to be completed by May 7, 2020. There was no documentation the training had been completed.
Employee # 7 was hired as a counselor on June 17, 2019. The HIV/AIDS and STD/TB training was to be completed by June 17, 2020. There was no documentation the training had been completed.
Employee # 10 was hired as a treatment aide on September 14, 2011. The HIV/AIDS training was to be completed by September 14, 2013. There was no documentation the training had been completed.
Employee # 11 was hired as a treatment aide on May 17, 2017. The HIV/AIDS training was to be completed by May 17, 2019. There was no documentation the training had been completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall ensure that all staff persons receive a minimum of 6 hours of HIV/AIDS training and at least 4 hours of tuberculosis, sexually transmitted disease and other health related topics training using a Department approved curriculum. Renewal Treatment, Inc. shall utilize a staff person or contracted external trainer who has attended this Department approved training to train all of the staff that are in non-compliance using the Department approved curriculum. This training is in the process of being scheduled. New hires will have the HIV/AIDS training scheduled as part of the new hire orientation process and while completing their initial training needs assessment. All staff will have their training audited by their supervisor during 6 month and annual evaluations to ensure they have completed all required training including HIV/AIDS and TB/STD training. Staff that have not completed their required training will have it scheduled at that time ensuring compliance with necessary time frames. Their training files will be audited twice a year ensuring compliance. Additionally,The VP of HR & Compliance shall ensure that in-house HIV/AIDS ( 6 hrs.) and STD/TB (4 hrs.) training are scheduled and all non-compliant staff shall be scheduled for this training. This plan of correction is in place. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
The facility failed to conduct a fire drill during sleeping hours at least every 6 months.
A review of the fire drill log was conducted on July 14, 2020. The last documented fire drill during sleeping hours occurred on December 30, 2019. An overnight fire drill was due to be completed by June 2020. There have been no overnight fire drills documented since December 30, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall perform fire drills on all shifts, including daylight and sleeping hours. The Project Director and Director of Security has received instruction on this requirement and will ensure that fire drills occur monthly and shall rotate between daylight and overnight (sleeping hours) at least every 6 months. The Project Director and Director of Security shall be responsible for the scheduling of the fire drills and shall ensure compliance with this Plan of Correction. This Plan of Correction is currently in place. |