INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 28, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, GPHA Dental and Behavioral Health Care Center 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 (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 personnel records, the facility failed to ensure all personnel on all shifts were trained to perform assigned tasks during emergencies in one of one applicable personnel record reviewed.Employee #5 was hired at this facility as a counselor on January 2, 2024. There was no documentation of the employee receiving the emergency preparedness training as of the date of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
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.
Observations:
To ensure full compliance with 705.28(d)(3) moving forward, all transferred employees and employees who work at multiple sites will undergo additional Fire Safety Training for the newly assigned location on their initial start date at that location. The following steps will also be taken to bring the existing employee into compliance on August 2, 2024.
Interactive training will include placement of fire extinguishers, fire alarm pulls, emergency exits, building evacuation procedures, and facility meeting locations. The employee must take a post-test and obtain a passing score. The facilitator will generate a facility fire safety form, date, sign, and get the employee's signature, acknowledging participation in the training. Additionally, the employee must complete a refresher course on using fire extinguishers in GPHA's training portal. The facilitator will submit a copy of the facility fire safety form to the QA department for monitoring and to HR for placement in the employee's credentialing file. The site director will maintain the original document on-site. The QA Manager and Site Director will monitor this process continuously whenever a relocation or multiple locations occur. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's June 2023 through June 2024 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts. The facility's hours of operation were posted as Monday, Wednesday, Friday from 8:30AM to 5:00PM and Tuesday and Thursday from 8:30AM to 8:00PM. There were thirteen fire drills completed during the reviewed period, two of the drills were conducted at 3:30PM and the remaining eleven drills were conducted between 11:30AM and 12:30PM. None of the fire drills were conducted during the Tuesday or Thursday evening hours of operation.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.28 (d) (6) LICENSURE
Fire safety.:
705.28. Fire safety. (d) Fire drills. The nonresidential facility shall: (6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
In order to comply with standard 705.28(d(6)) on fire safety and fire drills being conducted on different days of the week, at other times of the day, and on various shifts, the following corrective action has been implemented:
A fire drill tracking form was developed to ensure fire drills are conducted during all shifts. Safety and Security Officers were trained on the fire drill tracker on July 26, 2024. The Safety and Security Officers were instructed to review the tracking form before performing the next fire drill to determine the day, date, and time of prior drills this calendar year to avoid date, day, or time patterns moving forward. The Safety and Security Officers must strategically plan fire and other safety drills to ensure drills are placed during all shifts.
Safety and Security Officers are instructed to discuss only the pending monthly drill with the QA manager to ensure they comply with 705.28 (d)(6) before facilitating the drills.
The Quality Assurance Manager will monitor and track fire drill compliance monthly. The fire drill tracking form will be presented by QA Manager during site leadership meetings. A summary of the fire drill report will be provided to the BH leadership quarterly. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on an administrative review, the governing body failed to make available to the public an annual report, which is to include but not be limited to a statement disclosing the names of officers, directors, and principal shareholders, as required if a facility is publicly funded.This finding was discussed with facility staff during the licensing process.
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Plan of Correction
709.22 (c) LICENSURE
Governing Body:
§ 709.22. Governing body. (c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
To comply with 709.22 (c), the annual report due date has been adjusted from June 30 to June 15 to ensure that the annual report will be completed prior to the yearly audit date. The annual report policy has been revised to reflect the adjusted date and will be presented to the policy committed at the next meeting on August 13, 2024.
Additionally, an exception has been added to the policy: if an annual report is requested before the date outlined in the policy, the annual report writers will provide a brief version of the annual report indicating when the full version will be available and posted for public view. |