INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 31, 2008 through August 1, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare York Pharmacotherapy Services 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 and a plan of correction is due on September 1, 2008.
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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 a review of six personnel records on July 31, 2008, five were required to have documentation that staff were instructed in the use of the fire extinguisher. The facility failed to document in personnel records #2, 3, 4, 5 and 6 that staff were instructed within seven days from the date of employment.
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Plan of Correction
All staff have received formal fire extinguisher training. All staff will sign off on the new form stating that they have received this training by 8/19/08. All new employees will also complete fire extinguisher training within 7 days of hire and sign off on the new form indicating they have received this training. The new forms will be kept in the training file for each employee. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of documentation in the fire drill record on August 1, 2008, the facility failed to prepare alternate exit routes to be used during fire drills.
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Plan of Correction
The fire drill form has been revised to include a line listing the exit routes used. Effective immediately exit routes during fire drills will be rotated and documented on the new form. |