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 April 24, 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, Holcomb Associates, 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on an administrative review, the facility failed to instruct all staff in the use of the fire extinguisher upon staff employment in one of fourteen personnel records reviewed.
Employee #7 was hired as a counselor on October 2, 2019. There was no documentation of completed training in the use of fire extinguishers until April 21, 2020.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Emplyee #7 completed Fire Extinguisher and Safety training on 4/21/2020. This training was inadvertently taken out of new employee orientation during a time when the organization was restructuring the orientation process. This training has also been added back into the New Orientation Process upon first day of hire. Staff can also now access trainings anytime through our Learning Management System/Electronic HR training system. Additionally, the Clinical Coordinator will create a check list for all mandatory trainings for new or transferred staff to complete upon hire. If a training is missing, the Clinical Coordinator will follow up the new or transferred employee and with Human Resources. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on an administrative review of the May 2019 through March 2020 fire drill logs, the facility failed to conduct an unannounced fire drill for the month of October 2019.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Moving forward, the Regional Director is pre-scheduling in a shared outlook calendar that a fire drill will be completed every month, varying days and times when the drill is held. Clinical Coordinator will ensure that the fire drills are completed each month by the Director and Environment of Care Representative/Staff. In addition, the drills are submitted to Quality Management each month to review and ensure compliance. |
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 an administrative review, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in two of fourteen personnel records reviewed.
Employee # 6 was hired as a counselor on August 5, 2019. There was no documentation in the personnel record that they were trained to perform tasks during emergencies.
Employee #10 was hired as a counselor on August 12, 2019. There was no documentation in the personnel record that they were trained to perform tasks during emergencies.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee #6 completed General Emergency Guidelines on 5/2/2020. Employee #10 completed General Emergency Guidelines on 4/23/2020. Emergency Guidelines training was inadvertently taken out of new employee orientation during a time when the organization was restructuring the orientation process. This training has since been added back in via our Learning Management System/electronic HR training system. Employees cannot complete orientation now without this training. Employees will not start (and existing employees transferring to this program) will not occur until orientation is completed. Additionally, the Clinical Coordinator will create a check list for all mandatory trainings for new or transferred staff to complete upon hire. If a training is missing, the Clinical Coordinator will follow up with the new or transferred employee and with Human Resources. |