INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 23 and 24, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Recovery Revolutions, 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 and a plan of correction is due on March 25, 2011.
|
Plan of Correction
|
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
|
Observations
Based on a review of personnel records and an interview with the project/facility director, the facility failed to document the results of a reference investigation in two of four personnel records, as required.
The findings include:
Four personnel records were reviewed on February 23, 2011. Four personnel records required reference investigations. Per regulation, the personnel records shall include the results of reference investigations. Personnel records # 4 did not include the results of a reference investigation. Record #4 was the only new hire since the last inspection.
Employee # 4 was hired on January 03, 2011. There was no documentation of a reference investigation in personnel record # 4.
The facility director was interviewed on February 23, 2011 and confirmed the facility failed to conduct a reference investigation for newly hired employee #4.
|
Plan of Correction
It was the understanding of the agency that background checks and called references (w/o documentation) were acceptable for personnel charts; however this issue was addressed at 2/24/2011 site visit.
A letter was placed in all past personnel files addressing this issue. As of 2/24/2011, it is Recovery Revolution's policy to document in the personnel file, a new hire's personnel references. This will include, documentation of phone calls, letters of personnel reference, board meeting/staff approval if they referred the person.
|
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on a physical plant tour on February 24, 201 at 10:30 am, the facility's handicap bathroom included a heater that was not permanently mounted or installed.
The findings include:
During the February 24, 2011 inspection, it was observed that the handicap bathroom included a heater that was not permanently mounted or installed. The director confirmed that the facility's use of the unmounted heater.
|
Plan of Correction
Due to a pipe freezing in our handicap downstairs bathroom, we were using a portable heater overnight in the facility. We were not using the portable heater since that time period however forgot to remove it from the premises. Since the inspection, all portable heaters have been removed from the building. At our 3/15/2011 staff meeting, the Executive Director discussed with all staff members that portable heaters were not allowed on premises. Since the portable heater was only on premise due the pipes freezing, we have fixed this problem by adding a baseboard heater to that room. The Executive Director will inspect the premises one time per month, to insure no heaters were brought into the facility. |
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.
|
Observations
Based on a review of the fire drill logs and an interview with the facility's director, the facility failed to document the time it took to complete the drills, 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.
The findings include:
Twelve months of fire drills were reviewed on February 23, 2011. Eight of the twelve fire drills reviewed failed to include documentation of the time it took to complete the drills, 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 at the time of the drill.
Fire drills recorded during the following months did not include the required information: 01-12-2011, 12-14-2010, 11-15-10, 10-25-2010, 08-18-2010, 07-20-2010, 05-17-2010, and 04-15-2010.
|
Plan of Correction
The fire drill log was an oversight of the Executive Director. More time and attention will be given to the fire drill log. The Executive Director, will document the fire drill in its entirety one time per month at the fire drill. The fire drills took place; it was documentation that was not completed. We will document the time of drills, the problems encounters and whether the fire alarm was operative at the time of the drill. The Executive Director is responsible for the oversight and will ensure that it is thoroughly documented |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill logs were reviewed on February 23, 2011. The facility failed to document any alternate exit used during fire drills for eight of twelve months reviewed. The facility failed to document the following exit routes used during every fire drill: 01-12-2011, 12-14-2010, 11-15-2010, 10-25-2010, 08-18-2010, 07-20-2010, 05-17-2010, 04-15-2010, and 04-15-2010. The director confirmed on February 24, 2011 in an interview that the facility failed to document alternate exits used on the monthly drills.
|
Plan of Correction
The Executive Director will document the exits used in the fire drill on a monthly basis. The fire drill log was an oversight of the Executive Director. More time and attention will be given to the fire drill log. The Executive Director, will document the fire drill in its entirety one time per month at the fire drill. The fire drills took place; it was documentation that was not completed. We will document the time of drills, the problems encounters and whether the fire alarm was operative at the time of the drill. The Executive Director is responsible for the oversight and will ensure that it is thoroughly documented |