INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12th and 13th, 2018 of Gateway Rehabilitation Center Inc. Moffett 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, Gateway Rehabilitation Center Inc. 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:
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Plan of Correction
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records on September 4th and 5th, 2018, there was no documentation of an employee performance review in employee #1's record. Employee #1 was hired on 5/2/2000 and promoted to her position on 2/12/2017. Employee record did not show an employee performance review for the year 2017.
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Plan of Correction
All Vice Presidents will receive PE October of that year. Yearly PE reviews will all be set to October VP, Human resources. GRC Human resource Dept will send out notice of pending PE evaluations 30 days prior. The Vice President of Human resources will oversee the completion of PE's for all Gateways Vice Presidents.
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705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection on September 12th, 2018, it was observed by the licensing specialist that several boxes of food were on the floor in the dry goods storage room. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On September 12, 2018 shelves were purchase ensuring that all dry goods would not be on the floor. The facility manager met with life skills coordinator to review process. The life skill coordinator will complete a weekly inventory ensuring that all food products are being stored properly.The life skills coordinator will conducts orientation with all Moffett House clients regarding storing of dry goods. The facility manager will conduct monthly checks of dry store area. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
A review of the September 2017 through August 2018 fire drill logs was conducted during the on-site inspection on September 13th, 2018. For all months reviewed, it was documented on the logs that the "designated exit used in drill: rear entrance". The facility failed to utilize alternative exit routes during the fire drills.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gateway Moffett House conducts monthly fire drill. Moffett House Staff will begin using the alternative exit during some of the drills. The drill is documented in GRC D-3 system. The manager of facility will review all fire drills ensuring the alternative exit in being used in drills. The Director will conduct a semi-annual review of fire drills by usage of D-3 system. This process will support the usage of the alternative exit. |