INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago Pottsville 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 as required by regulation in one of three personnel records.
The findings include:
Three personnel records which required documentation of fire extinguisher training upon employment were reviewed on August 7, 2013. The facility failed to document that fire extinguisher training was completed upon employment in employee record # 8.
Employee # 8 was hired on 2/19/13. Fire extinguisher training was due to be completed upon employment. As of the date of the inspection, there was no documentation of the completion of fire extinguisher training in this employee record.
The Facility Director confirmed the findings.
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Plan of Correction
The facility director will be responsible to complete fire extinguisher training with all new hire staff within the first week of hire. Corporate Compliance Officer along with the facility director will conduct audits of all new hire staff personnel folders to ensure compliance. Employee #8 as identified in the POC at time of inspection, August 7, 2013 was terminated for Job Abandonement. |
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, the facility failed to ensure that all personnel were trained to perform assigned tasks during emergencies in one of three personnel records reviewed.
The findings include:
Three personnel records which required documentation of training to perform assigned tasks during emergencies were reviewed on August 7, 2013. The facility failed to document that emergency training was completed upon employment in employee record # 8.
Employee # 8 was hired on 2/19/13. Emergency training was due to be completed upon employment. As of the date of the inspection, there was no documentation of the completion of emergency training in this employee record.
The Facility Director confirmed the findings.
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Plan of Correction
The facility director will be responsible to complete fire extinguisher training with all new hire staff within the first week of hire. Corporate Compliance Officer along with the facility director will conduct audits of all new hire staff personnel folders to ensure compliance. Employee #8 as identified in the POC at time of inspection, August 7, 2013 was terminated for Job Abandonement. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on client record review, the facility failed to document a discharge summary in one of three client records.
The findings include:
Three client records which required documentation of a discharge summary were reviewed on August 7, 2013. The facility failed to document a discharge summary in client record #6.
Client # 6 was admitted on 4/30/13 and discharged on 5/5/13. This client record did not contain a discharge summary as of the date of the inspection.
The Compliance Officer and Facility Director confirmed the findings.
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Plan of Correction
The Corporate Clinical Director will conduct a training in the Pennsylvania Department of Health Clinical Documentation requirements and documentation timeline requirements with all clinical staff to ensure compliance with DOH regulations. The Facility Director along with the Corporate Compliance Officer will complete monthly chart reviews of discharged clients to ensure all clinical documentation requirements are being met. |