INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the December 12, 2011 licensure renewal inspection. The follow-up inspection was conducted on October 26, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Community Service Foundation, 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 personnel records, first aid cards and Cardio Pulmonary Resuscitation (CPR) certifications, the facility failed to ensure that a sufficient number of staff persons in first aid and CPR skills are present during all the project's hours of operation.
The findings include:
On October 26, 2012, a first aid and CPR certification card and the facility's first aid and CPR certification training sign-in sheet were reviewed. The facility is open Monday through Thursday from 8:00 A.M. to 4:00 P.M. and Friday from 8:00 A.M. to 3:00 P.M. Only one staff member, a counselor, had documentation of first aid training and CPR certification. One staff member was not enough to provide sufficient first aid and CPR coverage for the hours of operation.
The findings were confirmed during an interview with the project director on October 26, 2012 at approximately 11:00 A.M.
This is a repeat citation. The facility was cited on December 12, 2011 for noncompliance with this standard.
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Plan of Correction
The project director will ensure that at least two staff members are certified at each location. The project director is ensuring that all locations are in compliance by keeping a log of CPR training and keeping copies of certification cards. We are currently in compliance as of 11/13/12. |
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.
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Observations
Based on a review of fire drill records, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
Fire drill records were reviewed on October 26, 2012. The records were reviewed from the period covering January 2012 to September 2012. The facility did not have documentation of an unannounced fire drill in three of the nine months reviewed, specifically, March 2012, July 2012, and August 2012
The findings were confirmed during an interview with the project director on October 26, 2012 at approximately 11:00 A.M.
This is a repeat citation. The facility was cited on December 12, 2011 for noncompliance with this standard.
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Plan of Correction
The project director will ensure that unannounced fire drills will be completed monthly (even in the summer months). The fire drill log was recently changed to include more specific information and to ensure it is done every month. The project director will ensure the programs are in compliance starting 11/13/12. |