INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 1, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Silvermist, LLC 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.
|
Plan of Correction
|
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.
|
Observations
Based on a review of the facility's staffing work schedule, and CPR certification cards; the facility failed to provide a sufficient number of staff persons trained in CPR, so that at least one person trained in these skills was onsite during the project's hours of operation.
The findings include:
The staffing schedule for April, 2015 and CPR certification cards were reviewed on May 1, 2015. The program is a 24 hour residential facility. There was no documentation that a sufficient number of staff persons trained in CPR were onsite during the project's hours of operation for the weeks April 5, 12, 19, and 26, 2015.
For the week of April 5, 2015, there was no documention of CPR coverage on April 11, 2015 from 12 AM to 8 AM.
For the week of April 12, 2015, there was no documention of CPR coverage on April 18, 2015 from 4 PM to 12 AM.
For the week of April 19, 2015, there was no documention of CPR coverage on April 22, 2015 from 11:30 PM to 12 AM and April 23, 2015 from 11:30 PM to 12 AM.
For the week of April 26, 2015, there was no documention of CPR coverage on April 28, 2015 from 11:30 PM to 12 AM.; and April 29, 2015 from 11:30 PM to 12 AM.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
All front line support staff will be trained in CPR within 90 days of employment. Staff schedules created will be reviewed to ensure one CPR certified staff on on every shift at all times with no exceptions. Program Director will review weekly schedules prior to their initiation to ensure compliance. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential 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.
|
Observations
Based on the physical plant inspection, the facility failed to ensure that the fire extinguishers were inspected and approved by the local fire department or fire extinguisher company.
The findings include:
The plant inspection was conducted on May 1, 2015. The fire extinguishers had been inspected by the facility maintenance department. There was no documentation that the fire extinguishers were inspected and approved by the local fire department or fire extinguisher company.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 5/8/2015, PFE Corporation came and inspected all fire extinguishers. Maintenance will ensure the functionality of each fire extinguisher is monitored on a monthly basis. Maintenance will document monthly inspections and keep annual records of PFE Corporation's inspection. Program Director will oversee documentation to ensure compliance. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in the client record that included; the name of the person, agency or organization to whom disclosure is to be made, specific information to be released and/or the dated signature of the client in five of ten client records.
The findings include:
Ten client records were reviewed on May 1, 2015. Ten client records were reviewed for informed and voluntary consents. Client records # 2, 4, 6, 8 and 9 did not include the name of the person, agency or organization to whom disclosure is to be made, specific information to be released and/or the dated signature of the client.
Client # 2 was admitted on April 11, 2015. A consent to release information, signed by the client on April 29, 2015, did not document the name of the person, agency or organization to whom disclosure was to be made.
Client # 4 was admitted on January 11, 2015. A consent to release information, signed by the client on January 11, 2015, did not document the name of the person, agency or organization to whom disclosure was to be made.
Client # 6 was admitted on January 31, 2015. A consent to release information to the client's mother did not include the dated signature of the client.
A consent to release information to the client's funding source did not include the dated signature of the client.
A consent to release information to the client's father did not include the dated signature of the client.
Client # 8 was admitted on October 28, 2014. A consent to release information to the client's mother, signed by the client on October 28, 2014, did not include the specific information to be released.
A consent to release information to the client's father, signed by the client on October 28, 2014, did not include the specific information to be released.
A consent to release information to the probation officer, signed by the client on October 28, 2014, did not include the specific information to be released.
Client # 9 was admitted on March 31, 2015. A consent to release information to the client's funding source, signed by the client on March 31, 2015, did not include the specific information to be released.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
All staff received re training information on 5/11/2015 regarding the proper completion of consents. Completion of consents was added to the open and closed monthly chart monitors. Program Director will review monthly chart monitors to ensure compliance. |