INITIAL COMMENTS
|
This report is a result of an on-site licensing inspection conducted on December 12, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Community Service Foundation, Inc. Bethlehem 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.
|
Plan of Correction
|
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.
|
Observations
Based on a review of facility staff CPR/first aid certification cards, the facility failed to ensure that at least one person trained in CPR skills onsite during the project's hours of operation.
Findings:
Based on a review of staff on December 12, 2011 and staff CPR/first aid certification cards, the facility failed to have sufficient staff trained in these skills on duty.
Only one staff was certified to perform CPR/first aid in case of an emergency. In order to provide coverage for all hours of operation, other staff need to be trained.
|
Plan of Correction
Each facility has one CPR/first aid current certified person trained. By April 1, 2012 the executive director and clinical supervisor will ensure that additional staff are certified to ensure that at lease two staff are certifed at the facility for each day, in case of a staff absence another staff person is certified. The executive director has already scheduled the CPR/first aid training and will continue certification trainings annually to keep certifications current. |
705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
|
Observations
Based on a review of the physical plant, the facility failed to maintain at lease two exits in the basement.
The findings include:
A tour of the physical plant on December 12, 2011, established the facility failed to maintain two exits on the one side of the basement. The basement is divided by a foundation wall which divides the basement into two sections. One side of the facility is used for the Science class. There are steps leading to the basement and the second exit leads outside to the patio area. The other side of this basement has only one exit. At the time of the inspection the facility was using the basement space as an office.
|
Plan of Correction
The facility will be submitting an exception for the use of this office. A letter with supplemental documentation, pictures and reports will be sent for consideration. The space in question is sprinklered with an annually inspected system. After ascending a 1/2 flight of stairs, a person has 2 means of egress. The area and the entire building is monitored 24 hours a day for fire and has been approved by Bethlehem City Fire Marshall and Labor and Industry. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of the fire drill record log, the facility failed to document monthly fire drills.
The findings include:
The fire drill record log was reviewed on December 12, 2011. The log was reviewed from December 2010 to December 2011. The facility failed to document fire drills for the months of June 2011, July 2011 and August 2011 . This finding was confirmed with the program coordinator on December 13, 2011.
|
Plan of Correction
There were no clients or staff during the summer at this facility. However, during the summer months when the outpatient program is operating, fire drills will be conducted and recorded. The project director and clinical supervisor will train summer program staff by 5/15/12 how to implement and document fire drills. Project director will ensure that all facilities conduct monthly fire drills at all locations regardless of client participation. |