Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, and the staff schedule the facility failed to ensure that at least one person trained in CPR and first aid is onsite during project's working hours.
There was not at least one person trained in CPR and first aid during the following time periods- August 1, 2026 8a-12p; August 2, 2026 8a-3p; August 8, 2026 8a-10p; August 9, 2026 8a-2p; August 15, 2026 8a-2p; August 16, 2026 8a-12p; August 22, 2026; August 29, 2026 8a-2p; August 30, 2026 8a-2p; September 5, 2026 8a-3p; September 6, 2026 8a-2p; September 12, 2026 8a-12p; and, September 13, 2026.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Since the deficiency was identified during the site inspection, 18 program staff have been trained and certified in CPR. There are 15 remaining staff that are scheduled to complete the training in October.
The Training Coordinator has established a recurring CPR training on the 3rd Thursday of each month, in perpetuity.
Each month, the Training Coordinator will refer to the training spreadsheet to identify any staff that have a certification expiring withing the next 3 month period. They will be scheduled to attend the training scheduled for that month.
The Facility Director will complete quarterly oversight checks on this process with the Training Coordinator. |