INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 8, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-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
Based on a review of personnel records, the facility failed to document that each employee completed TB/STD and HIV/AIDS training within the required timeframes in one of four records.
Staff #1 was hired as the project director on September 17, 2018. TB/STD and HIV/AIDS training was due to be completed by September 17, 2020. There was no documentation of HIV/AID or TB/STD training in staff record #1.
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 the Department approved training to train all of the staff that are in non-compliance using the Department approved curriculum. This training is currently being scheduled and will be completed by 12/31/2021. New hires will have the HIV/AIDS training scheduled as part of the orientation process and during completion of their training needs assessment. All staff will have their training files audited 2 times a year as part of the evaluation process by their supervisor. Staff that have not met this training requirement will be scheduled for the training at that time. Additionally, the VP HR and Compliance shall ensure that in-house HIV/AIDS (6 hrs.) and STD/TB (4 hrs.) trainings are scheduled and all non-compliant staff are scheduled for this required training at that time. The VP HR and Compliance shall be responsible for this plan of correction. This plan of correction is in place. |
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 a review of fire drill records, the facility failed to maintain a fire drill record which included the exit route used.
Fire drills were reviewed for the time period of August 2020 - August 2021. The fire drills conducted in the months of June, April, March, February and January 2021 as well as December, November, October and September 2020 did not include documentation of the exit route used.
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 a monthly basis and shall document the exit route used during the fire drill on the Fire Drill Form. The security staff that are performing the fire drill shall complete the Fire Drill Form and shall document the exit route on this document. The Security Supervisory staff have provided instruction to the security staff on this requirement and shall review the Fire Drill Form each time there is a fire drill to ensure it is completed in its entirety including the exit route. The Security Supervisory staff shall sign off on the form after this review. Additionally, all Fire Drill Forms will be emailed to the VP HR and Compliance who shall review them and shall ensure compliance. The VP HR and Compliance shall be responsible for this plan of action. This plan of action is in place. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates at least every 60 days in three of seven client records.
Client #5 was admitted on January 22, 2021 and discharged on July 7, 2021. Client #5 had a treatment plan dated January 22, 2021. Treatment plan updates would have been due March and May 2021. There was documentation of one treatment plan updated dated May 6, 2021.
Client #6 was admitted on February 24, 2021 and discharged on July 15, 2021. Client #6 had a treatment plans dated March 15 and May 6, 2021. A treatment plan update would have been due by July 6, 2021.
Client #7 was admitted on February 23, 2021 and discharged on June 7, 2021. Client #7 had a treatment plans dated February 23 and March 5, 2021. A treatment plan update would have been due by May 6, 2021.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 7, 2021 inspection.
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Plan of Correction
Renewal Treatment, Inc. treatment staff shall perform and document a treatment plan update at least every 60 days. The Clinical Supervisor and Clinical Director provided instruction and training to the treatment staff on this requirement. The Clinical Supervisors shall ensure compliance via regular documented file audit. The Clinical Supervisors and Clinical Director shall be responsible for this plan of correction and shall ensure compliance. This plan of correction is in place. |