INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 11, 2016, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clem-Mar House Inc 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 facility CPR/First Aid cards and the resident managers work schedule provided provided during the presubmission process, and during the onsite inspection, the facility failed to document that a sufficient number of staff persons were trained in CPR and first aid to ensure that at least one staff person trained in these skills was onsite during the project's hours of operation.
The findings include:
The facility failed to document that there was a staff person onsite trained in CPR and first aid from 4:30PM to 12:00AM on the following dates: 12/28/15, 12/29/15, 01/02/16, 1/5/2016, 1/06/2016, 1/11/16, 1/13/2016, 1/16/16, 1/18/16, 1/20/16, 1/23/16, 1/24/16, 1/25/16, 1/27/16
The facility failed to document that there was a staff person onsite trained in CPR and first aid from 12:00AM to 8:00AM on the following dates: 1/18/16, 1/19/16, 1/20/16.
The findings were reviewed with facility staff during the inspection process.
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Plan of Correction
Upon hire, all employees are given a Training Plan containing required trainings and times frames for the employee to complete the trainings. Immediately following the site visit, the Clinical Director reviewed all RM staff trainings to check for certification. CPR and First Aid certification is required for all Resident Managers. The Clinical Director will not permit any employee to work alone without being trained in these areas. The Clinical Director will review staff certifications in CPR and First Aid on a monthly basis to ensure compliance with this regulation. The Clinical Director immediately began a monthly review of staff certifications following the site visit. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on an onsite inspection of the facility's physical plant, the facility failed to ensure that the hot water temperature in the facility bathrooms did not exceed 120 degrees Fahrenheit.
The findings include:
The hot water temperature for both bathrooms on the second floor when tested were 133.0 degrees Fahrenheit.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
The Clinical Director immediately met with the maintenance worker the same day of the site visit and he went downstairs and adjusted the temperature of the water to be below 120 degrees Fahrenheit. The importance of the water being below this temperature was discussed with him to be in compliance with this regulation. To ensure on going compliance with this regulation, the Maintenance worker shall monitor the water temperature on a weekly basis. |