INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 15th, 2019 of ADAPPT House by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, ADAPPT House 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #9, 10, 11 and 12 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #9 was hired as maintenance on May 27, 2011 and was due to have the communicable disease trainings no later than May 27, 2013. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #10 was hired as administration on July 5, 1994 and was due to have the communicable disease trainings no later than July 5, 1996. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection
Employee #11 was hired as a shift supervisor on September 6, 2016 and was due to have the communicable disease trainings no later than September 6, 2018. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection
Employee #12 was hired as a security monitor on December 7, 2016 and was due to have the communicable disease trainings no later than December 7, 2018. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection
The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
As of February 21, 2019, employees 9, 10, and 11 have completed the required HIV/AIDS and TB training. Certificates of completion have been placed in their respective personnel/training files. To confirm all current staff has received the required HIV/AIDS and TB training, the office support services manager (OSS) will conduct a review of all personnel/training files to identify staff who has not completed the training. Any identified staff, including employee 12, will be immediately scheduled for the required training, with an anticipated completion date of March 14, 2019. In an effort to eliminate a reoccurrence, the OSS manager will conduct an initial review, and monthly thereafter, of applicable personnel files to validate staff have received the required training. Additionally, the facility director will request training for both himself and the OSS manager on the use of the GEO Learning Management System to schedule and track all employee training.
Person(s) Responsible: HR Manager
Facility Director
|
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.
|
Observations
Based on Review of the staffing Requirements facility summary report and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the project/facility director in employee #1 ' s employee record.
These findings were reviewed with facility staff during the licensing process
|
Plan of Correction
Prior to March 31, 2019, the project director will develop and submit a curriculum that includes both initial and annual training. The annual training will be at least 12 clock hours. Once the curriculum is approved, the training will be completed. The facility director or designee will enter the completed training into the GEO Learning Management System (LMS) for tracking purposes. Additionally, all training documentation will be filed in the employee's personnel/training record.
Person(s) Responsible: Project Director
Facility Director |
705.6 (1) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(1) Provide bathrooms to accommodate staff, residents and other users of the facility.
|
Observations
Based on a physical plant inspection on January 15th, 2019, the facility failed to ensure that water temperature does not exceed 120F. The facility also failed to ensure that the residential male bathroom was supplied with toilet paper at all times.
The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Beginning immediately, facility maintenance personnel will monitor water temperatures weekly, documenting the temperatures of each tested area on the Safety & Sanitation Log. If any area is found noncompliant, the water will immediately be adjusted to the appropriate temperature. As part of their daily shift rounds, security staff will ensure resident bathrooms have an adequate supply of hygiene items including toilet paper. At any time, resident my request toilet paper if needed.
Person(s) Responsible: Maintenance/Security Staff
Facility Director |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
|
Observations
Based on the review of client records, the facility failed to document a completed form of consent to release information in client records, #2, 3 and 6.
Client #2 was admitted on January 2, 2019 and was still active at the time of inspection. A consent labled "Authorization to Disclose Health Information" dated January 3, 2019 failed to document who is authorized to release the information.
Client #3 was admitted on November 30, 2018 and was still active at the time of inspection. A consent labled "Authorization to Disclose Health Information" dated November 30, 2018 failed to document who is authorized to release the information.
Client #6 was admitted on June 27th, 2018 and was discharged on July 7th 2018. A consent labled "Authorization to Disclose Health Information" dated June 27, 2018 failed to document who is authorized to release the information.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Prior to March 31, 2019, the clinical supervisor had provided training to all clinical staff regarding Standard 709.28(c), specifically the importance of obtaining a signed informed and voluntary consent form prior to release or disclosure of resident information. To validate sustained compliance, moving forward the clinical supervisor will review all new resident intake files within 7 days of admission to confirm all forms of Authorization to Disclose Health Information identifies GEO ADAPPT Staff as the party that can disclose information. Any discrepancies will be immediately corrected. Additionally, file reviews will be documented on the 30-day supervisor review form.
Person(s) Responsible: Clinical Supervisor
Facility Director
|
709.14(b)(1) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
|
Observations
Based on a review of administrative documentation, and conversation with facility staff during the licensure inspection conducted on January 15, 2019, the facility was unable to provide verification that they had submitted documentation to notify the department within 90 days of change in ownership.
During the licensure inspection conducted May 1-2, 2018, the facility staff indicated that they had just been taken over by another company. They had not filed any documentation at that time. However, because 90 days had not yet passed since the change in ownership, they were not yet out of compliance with the regulation and were advised to submit the forms within the 90 day period.
|
Plan of Correction
Prior to February 28, 2019, change of ownership forms will be sent to GEO's corporate office for review and approval. Once the forms have been complete, they will be immediately forwarded to the Department.Moving forward we will notify DDAP of any changes
Person(s) Responsible: Facility Director |