INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 4 - 5, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, St. John Vianney Center 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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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 the Staffing Requirements Facility Summary Report and a conversation with the quality assurance director, the facility failed to ensure that the transportation driver was trained in CPR certification and first aid training.
The findings include:
A review of the Staffing Requirements Facility Summary Report that was completed by the facility on 6/4/13 indicated that the facility had a van driver. The facility failed to ensure that the van driver was certified in CPR and first aid training.
During an interview on June 4, 2013 the quality assurance director confirmed that the van driver was not certified in either CPR or first aid training.
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Plan of Correction
The Director of Human Resources is responsible for the corrective action plan and for the overall and ongoing compliance.
The Director of Human Resources will update the position requirements of all job descriptions of staff members who are responsible for driving patients to include CPR and First Aid certifications. The Director of Human Resources will audit the personnel files of all staff responsible for driving patients to identify which staff have not completed the required CPR and First Aid certifications. The Director of Human Resources will identify a training resource and schedule staff to attend the required certification classes. The Director of Human Resource will track certification expiration dates to ensure that staff maintain current certifications. The van driver will complete CPR and First Aid certifications on 7/24/13. Other staff who have completed CPR and First Aid training will be utilized for transporting patients until 7/24/13.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's fire drill log, the facility failed to maintain a written fire drill record including the number of persons in the facility at the time of the drill.
The findings include:
On June 4, 2013, the facility's fire drill log was reviewed covering the period from July 2012 through June 2013.
The facility's fire drill log failed to include the number of persons in the facility at the time of the drill.
The quality assurance director confirmed the findings.
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Plan of Correction
The Safety Officer is responsible for the corrective action plan and the ongoing compliance.
The Safety Officer revised the Fire Drill Evaluation Record to include the number of patients and staff that were evacuated on 6/14/13.
The Safety Officer will conduct quarterly audits of the Monthly Fire Drill/Evacuation Evaluation Records to insure compliance effective 6/14/13.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's fire drill log, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
On June 4, 2013, the facility's fire drill log was reviewed covering the period from July 2012 through June 2013.
The facility failed to set off a fire alarm or smoke detector during three of eleven fire drills conducted, specifically on May 2013, March 2013, and February 2013. The fire drill log documented "silent drills."
The quality assurance director confirmed that neither the fire alarm nor smoke detector was set off during these "silent drills."
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Plan of Correction
The Safety Officer is responsible for the corrective action plan and the ongoing compliance.
The Safety Officer was re-educated on the fire safety regulations requiring unannounced actual fire drill evacuations monthly by the Director of Quality Improvement and Regulatory Compliance on 6/10/13.
The Safety Officer will conduct actual evacuation fire drills monthly by activating a fire alarm or smoke detector effective 6/10/13.
The Safety Officer will report quarterly on Fire Drill/Evacuation Evaluations at the Environment of Care Committee.
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709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based on observation during a physical plant inspection, the facility failed to post a service fee schedule in a prominent place.
The findings include:
A physical plant inspection was conducted on June 5, 2013 at approximately 10:30 AM.
The facility failed to post a fee schedule in a prominent place.
The quality assurance director confirmed that the fee schedule was not posted.
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Plan of Correction
The Program Director is responsible for the corrective action plan and for the overall and ongoing compliance.
The Program Director posted a service fee schedule in the group therapy room on the patient care unit on 6/28/13. The Program Director will make monthly rounds to ensure that the fee schedule is posted and that the posted fees are current.
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