INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 6, 2014 and November 7, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, My Sister's Place Thomas Jefferson University 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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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the Facility failed to instruct staff in the use of the fire extinguisher upon staff employment in two of three personnel records reviewed.The findings include:Three personnel records were reviewed which required documentation of fire extinguisher training upon staff employment. The facility failed to ensure that employees # 3 and 4 completed fire extinguisher training upon employment.Employee # 3 was hired as a counselor on April 28, 2014. The employee did not complete fire extinguisher training until May 8, 2014.Employee # 4 was hired as a counselor on September 28, 2014. The employee did not complete fire extinguisher training until October 7, 2014.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure there is an effective tracking system in place for all new hires, monitoring the 7-day window for fire extinguisher training will be tracked through Microsoft Explorer; alternate back-up for primary trainer has been implemented. All trainings are documented in the staff training file. The Cook(Fire Chief) will be the lead staff responsible for this training. Back-up staff will be the Residential Director.
Staff responsible: Residential Director,Administrative Assistant, Lead House Manager, and Cook.
Timeframe for completion: 12/8/14 |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on observations on November 7, 2014, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.The findings include:A physical plant inspection was conducted on November 7, 2014. It was observed during the inspection from approximately 1:00 P.M. to 2:00 P.M., that the following fire extinguishers in the facility had not been inspected and approved by the local fire department or fire extinguisher company since June 2013:1)Two fire extinguishers in the kitchen on the first floor and two other fire extinguishers on the first floor.2)Two fire extinguishers on the second floor.3)One fire extinguisher on the third floor.4)Two fire extinguishers on the fourth floor.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All fire extinguishers have been inspected, updated, and meet all fire and safety requirements. Colored forms have been added to the Fire Drill book as a visual reminder notice for both Ansul System and the yearly fire extinguisher inspection. The new Jefferson vendor has been on-site to provide a quote for the program. The Cook(Fire Chief) will be the lead staff responsible for this training. Back-up staff will be the Residential Director. "The Cook (Fire Chief) will make sure all fire extinguishers are inspected and approved annually every year by a local fire department or fire extinguisher company."
Staff responsibel: Residential Director, Cook
Timeframe for completion: 11/12/14
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 the facility's fire drill records, the facility failed to ensure all personnel on all shifts were trained to perform assigned tasks during emergencies in two of three personnel records reviewed. In addition, the facility failed to maintain a written fire drill record including the exit route used in the facility at the time of the drill in four of eleven months reviewed. The findings include:Three personnel record requiring documentation that personnel had been trained to perform assigned tasks during emergencies were reviewed prior to November 6, 2014. The facility failed to ensure that employees # 3 and 4 had completed emergency training prior to working their first shift at the facility. Fire drill records were reviewed prior to November 6, 2014. The records were reviewed from the period covering November 2013 to September 2014. The facility did not maintain a written fire drill record including the exit route used in the facility at the time of the drill on 11/17/13, 1/10/14, 3/26/14, and 9/26/14. Employee # 3 was hired as a counselor on April 28, 2014. The employee did not complete emergency training until May 8, 2014.Employee # 4 was hired as a counselor on September 28, 2014. The employee did not complete emergency training until October 7, 2014.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A documented all staff emergency training was completed on 11/21/14 to review the proper execution of the form when completing a drill, with special emphasis in identifying the exit(s) used at the time. The Cook(Fire Chief) will be the lead staff responsible for this training. "The Cook (Fire Chief) will make sure all new employees complete emergency training prior to working their first shift. Also, the Cook (Fire Chief) will make sure that the facility maintains a written fire drill record that includes documentation of the exit route used in the facility at the time of drill." Back-up staff will be the Residential Director.
Staff Responsible: Residential Director and Cook
Timeframe for completion: 11/21/14 |