INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 6, 7,8 and 9, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, PA Care LLC, DBA Miners Medical 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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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical plant inspection, the facility failed ensure that the hot water temperature does not exceed 120 F.
The findings include:
The physical plant inspection took place on November 8, 2012 at 4:30 pm. During the inspection of the restrooms showed that the water temperatures exceeded the required 120 F. The staff restroom hot water temperature read 130 F.
The facility director was immediately informed of the findings and the need to adjust the temperature on November 8, 2012.
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Plan of Correction
The facility failed to comply with regulation 705.24 stating that the water temperature may not exceed 120F. The facility director will insure that the hot water gage is turned down on the hot water heater and will monitor monthly the hot water temperature via a digital thermometer beginning during December 2012 monthly health and safety checks. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to document fire extinguisher training upon staff employment in four of ten personnel records.
The findings include:
Twelve personnel records were reviewed on November 8, 2012. Ten personnel records were reviewed to verify that staff had been instructed on the use of a fire extinguisher upon employment. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel records # 6, 7, 8 and 9.
Employee # 6 was hired on June 1, 2012. The facility documented fire extinguisher training with the employee signature. A date was not documented for verification of completion upon hire.
Employee # 7 was hired on October 11, 2010. The facility failed to document fire extinguisher training.
Employee # 8 was hired on February 8, 2012. The facility documented fire extinguisher training with the employee signature. A date was not documented for verification of completion upon hire.
Employee # 9 was hired on April 11, 2012. The facility documented fire extinguisher training with the employee signature. A date was not documented for verification of completion upon hire.
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Plan of Correction
The facility failed to comply with regulation 705.28 which requires that all staff be instructed on the use of the fire extinguisher and that the instruction be documented by the facility. The facility director will provide instruction and training to all staff on the use of the fire extinguisher and document this training in each staff member's personnel chart. It is the ongoing responsibility of the facility director to insure that each new employee receives the fire extinguisher training and that each training is documented in the employee's personnel chart. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of the fire drill logs, the facility failed to conduct fire drills during normal staffing conditions specifically during the first hours of operation.
The findings include:
A review of the fire drill logs was conducted on November 8, 2012. The fire drills conducted from November 2011 to October 2012 were reviewed. The facility documented fire drills occurring between 8:59 a.m. and 1:15 p.m. The facility provides services to a working population who present to the program between 6 a.m. and 8 a.m. with most of the facility activity being provided during that time frame.
The fire drill findings were reviewed with the facility director on November 8, 2012, and confirmed.
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Plan of Correction
The facility failed to comply with regulation 705.28 requiring that fire drills be conducted during normal staffing conditions. The facility failed to conduct fire drills during the first hours of operation. The facility director will conduct fire drills during all hours of operation to include the first few hours of daily operation, specifically between the hours of 5:30am and 8:00am. The first drill facilitated during these times will occur in the month of December 2012. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records, the facility failed to document that all personnel were trained to perform assigned tasks during emergencies upon staff employment in nine of ten personnel records
The findings include:
Twelve personnel records were reviewed on November 8, 2012. Ten personnel records were reviewed to verify that staff had been trained upon employment to perform assigned tasks during emergencies. The facility failed to document the training to perform assigned tasks during emergencies in personnel records # 2, 3, 4, 5, 6, 7, 8, 9, and 10.
Employee # 2 was hired on 2/6/2012. The facility documented emergency training on 7/23/2012. This was five months after hire.
Employee # 3 was hired on 6/6/2011. The facility documented emergency training on 7/23/2012. This was thirteen months after hire.
Employee # 4 was hired on 3/27/2012. The facility documented emergency training on 7/23/2012. This was four months after hire.
Employee # 5 was hired on 3/19/2012. The facility documented emergency training on 7/23/2012. This was four months after hire.
Employee # 6 was hired on 6/1/2012. The facility documented emergency training on 7/23/2012. This was one and one-half months after hire.
Employee # 7 was hired on 10/11/2010. The facility failed to document emergency training.
Employee # 8 was hired on 2/8/2012. The facility documented emergency training on 7/23/2012. This was five months after hire.
Employee # 9 was hired on 4/11/2012. The facility documented emergency training on 7/23/2012. This was three months after hire.
Employee # 10 was hired on 3/26/2012. The facility documented emergency training on 7/23/2012. This was four months after hire.
The emergency training findings were reviewed with the facility director on November 8, 2012, and confirmed.
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Plan of Correction
The facility failed to comply with regulation 705.28 requiring all new employees upon hire be trained to perform assigned tasks during emergencies. The facility did not conduct the Emergency training in a timely manner when employees were hired. The facility director will include the Emergency Training as part of the new employee orientation, effective 12/3/12, to insure that all new staff are trained to perform tasks during emergencies. |
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.
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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:
A review of the fire drill logs was conducted on November 8, 2012. The fire drills conducted from November 2011 - October 2012 were reviewed. The facility did not document any exits used during fire drills for 11/30/2011, 12/21/2011, 1/31/2012, 3/16/2012, 4/30/2012, 5/21/2012, 6/29/2012, 7/18/2012, 8/9/2012, and 9/5/2012.
The alternate exit findings were reviewed with the facility director on November 8, 2012, and confirmed.
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Plan of Correction
The facility failed to comply with regulation 705.28 to include alternate exit routes be used during fire drills. The facility director will begin effective December 2012, documenting the exits being used in the description of the drill and evaluation of the drill. The facility director will insure that the use of different exits occur during fire drills so employees are able to demonstrate knowledge of and ability to carry out the exit plan. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill logs, the facility failed to activate a fire alarm or smoke detector during each fire drill.
The findings include:
A review of the fire drill logs was conducted on November 8, 2012. The fire drills conducted from November 2011 - October 2012 were reviewed. The facility did not document that a smoke detector or fire alarm had been activated during fire drills for 12/21/2011, 4/30/2012, 5/21/2012, 6/29/2012, 7/18/2012, 8/9/2012, and 9/5/2012.
The activation of a smoke detector or fire alarm findings were reviewed with the facility director on November 8, 2012, and confirmed.
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Plan of Correction
The facility failed to comply with regulation 705.28 stating the use of and/or setting off fire alarms or smoke detector during each fire drill. The facility director will document on each fire drill form that the alarm was activated and request from the alarm company a print out of the day and time and alarm was activated effective December 2012. |