INITIAL COMMENTS
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This report is a result of an initial licensure inspection conducted on July 26, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Little Creek Lodge, 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)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of employee records and an interview with the Clinical Supervisor and Project Director, the facility failed to ensure that a sufficient number of staff were trained in First Aid and had current CPR certification to ensure coverage for all hours of operation.
The finding includes:
Five employee records were reviewed during the initial licensing inspection of July 26,2012. Additionally, the Clinical Supervisor and the Project Director were interviewed.
Employee record # 1 - the employee was hired on 4/8/11. No documentation of current CPR certification was included in the record.
Employee record # 2 - the employee was hired 9/13/10. No documentation of CPR certification was included in the record.
Employee record #3 - the employee was hired on 3/21/12. No documentation of current CPR certification was documented in the record.
Employee # 4 - the employee was hired 11/6/09. No documentation of current CPR certification was included in the record.
Employee # 5 - the employee was hired on 2/18/09. No documentation of current CPR certification was included in the record.
Both the Clinical Supervisor and the Project Director acknowledged that staff did not have current CPR certification. The findings were not disputed by the Project Director.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on the physical plant inspection, the facility failed to ensure that cooking utensils were stored in a clean enclosed area when not in use.
The finding includes:
The kitchen was inspected on July 26, 2012 after the mid- day meal. The cooking/serving utensils were not covered and were stored in the open on shelves in the kitchen area.
The finding was reviewed with the Project Director and was not disputed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on the physical plant inspection the facility failed to ensure that each stairway exceeding two steps had a well secured handrail.
The findings include:
A physical plant inspection was completed as part of the initial licensing inspection of July 26, 2012. Two sets of outdoor stairs with drops exceeding eighteen inches and two steps did not have secured handrails at the time of inspection .
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (b) (1) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(1) Maintain a minimum of one operable, automatic smoke detector on each floor, including the basement and attic.
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Observations
Based on the physical plant inspection the facility failed to ensure that a minimum of one smoke detector was installed in the attic.
The findings include:
A physical plant inspection was completed as part of the initial licensing inspection of July 26, 2012. As part of the physical plant inspection the attic of the facility was inspected. No smoke detector was installed in the attic. The Project Director and Clinical Supervisor also checked the attic and verified that no smoke detectors were installed.
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
Based on the physical plant inspection the facility failed to ensure that smoke detectors and fire alarms were maintained so that each person with a hearing impairment would be alerted in the event of a fire.
The findings include:
A physical plant inspection was completed as part of the initial licensing inspection on July 26, 2012. The facility failed to ensure that fire alarms and smoke detection devices which included strobe lights to alert the hearing impaired in the event of a fire were installed. No strobe lights were installed in the common areas or hallways used by the client population.
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(d)(1) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(1) The application for employment.
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Observations
Based on the review of employee records, the facility failed to document an application for employment in four of five employee records reviewed.
The finding includes:
Five employee records were reviewed during the initial licensing inspection on July 26, 2012.
Each employee record is required to have documentation of an employment application or a resume. Four of five records reviewed failed to document an employment application or resume.
Employee record #1 - This employee was hired on 4/8/11. No application or resume was documented.
Employee record # 2- This employee was hired on 9/13/10. No application or resume was documented.
Employee record #4 - This employee was hired on 11/6/09. No application or resume was documented.
Employee record # 5- This employee was hired on 2/18/09. No application or resume was documented.
The Project Director did not dispute the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on the review of employee records, the facility failed to document references for employment in five of five employee records reviewed.
The finding includes:
Five employee records were reviewed during the initial licensing inspection July 26, 2012.
Five of five personnel records reviewed failed to include documentation of employment references.
Employee record # 1- This employee was hired on. 4/8/2011. No references were documented at the time of the inspection.
Employee record # 2- This employee was hired on. 9/13/10. No references were documented at the time of the inspection.
Employee record # 3- This employee was hired on 3/21/12. No references were documented at the time of the inspection.
Employee record # 4- This employee was hired on 11/6/09. No references were documented at the time of the inspection.
Employee record #5 - This employee was hired on 2/18/09. No references were documented at the time of the inspection.
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(f)(3) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
(3) The requisite skills, knowledge and experience.
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Observations
Based on the review of employee records, the facility failed to document job descriptions which included a statement of the minimum skills and education in two of two support staff employee personnel records.
The finding includes:
Five employee records were reviewed during the initial licensing inspection on July 26, 2012. Two of these were for employees in support staff ( non- clinical ) positions. Two of two support staff job descriptions failed to include documentation of the requisite skills and knowledge for each position.
Employee record # 4- This employee was hired on. 11/06/2009. The job description did not include the requisite skills and knowledge for the position.
Employee record # 5- This employee was hired on. 02/18/2009. The job description did not include the requisite skills and knowledge for the position.
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |