INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 23, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Moffett 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 and a plan of correction is due on March 7, 2008.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel and training records, the facility failed to document an individual training plan in one of five records reviewed, #1.
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Plan of Correction
The President/CEO will complete an annual training plan for 2008 by February 25. The Vice President of Human Resources will review the plan and ensure that training hours are completed as scheduled. |
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 a review of training documentation, the facility failed to document a sufficient number of staff persons, so that at least one person trained in CPR certification and first aid training was onsite during the project's hours of operation. The facility did not provide documentation of CPR and first aid coverage for the Saturday day shift on December 1, 8, 15, 22 and 29, 2007 and for January 5 and 12, 2008. The facility failed to document CPR and first aid coverage for the day shift on Tuesday, December 25, 2007.
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Plan of Correction
All staff that are not up-to-date with CPR/1st aid certifications are no longer working shifts alone. Several of those staff have now completed their certification and others are scheduled for the near future. The Clinical Manager and Program Director will ensure that all shifts are covered by at least 1 staff that has a current certification. |