INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 11, 2007 through September 14, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Marworth 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 October 11, 2007.
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Plan of Correction
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and training records it was determined that the residential project failed to ensure all personnel are trained in emergency procedures within seven days of employment. A review of eight personnel and training records of staff hired since the prior survey of November 11, 2006 revealed that the facility failed to include documentation of emergency procedures training. An interview with the project director and quality assurance personnel on September 13, 2207 indicated three of the seven organizational departments provide the emergency procedures training within the seven days of employment. Four of seven departments attend emergency training semi-annually. Employment dates of the records reviewed ranged from October 2006 through July 2007.
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Plan of Correction
The Director of Quality Improvement is adding a review of the Emergency Preparedness Manual to the orientation checklist for all new hires in each department, including Conseling, Nursing, Admissions, Dietary, Medical Records, Administration and Outpatient. Department Heads are responsible for review of Emergency Manual within 7 days of hire. Orientation checklist will be maintained in Personnel Record. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs it was determined that the project failed to conduct a fire drill during sleeping hours every six months at the Family House residential building. The fire drill log and reports reviewed on September 12, 2007 for the period of December 2006 through August 2007 failed to document a drill during sleeping hours. An interview with the project director and quality assurance staff on September 13, 2007 verified the lack of sleeping hour drill at the Family House residential building for the period December 2006 through August 2007.
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Plan of Correction
Fire drills will be conducted during sleeping hours every 6 months. Drills to be conducted and documented by Maintenance Supervisor. First drill to be conducted on 9/26/2007. Subsequent drills to occur every 6 months and monitored by C.E.O. for consistency and timeliness. |
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
Based on reviews of fire drill logs and interviews with staff it was determined that the project failed to provide documentation of alternate exit route preparation during fire drills. Fire drill logs, reports and an interview with the project director and quality assurance staff on September 13, 2007 verified for the period of December 2006 through August 2007 that alternate exits had not been prepared during fire drills.
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Plan of Correction
Alternate exits will be noted on the fire drill form by placing a blue "X" at the alternate exits and a red "X" at the exits that are blocked by the fire. Responsible person: Maintenance Supervisor. |