INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensing inspection that was conducted on January 4, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from the on-site inspection, WES Corporation 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 supervisory review.
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Plan of Correction
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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 a review of personnel records, the facility failed to document the instruction of staff in the use of the fire extinguisher upon staff employment, in two of seven personnel records.
The findings include:
Seven personnel records were reviewed on January 4, 2016. Two personnel records were required to document fire extinguisher training. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel record #1 and #2.
Employee # 1 was hired on August 31, 2015. The training was due upon hire. The facility failed to document the completion of fire extinguisher training.
Employee #2 was hired on February 4, 2015. The training was due upon hire. The facility failed to document the completion of fire extinguisher training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each new full-time staff member are required to attend new employee orientation within the 1st month of employment, which includes Fire Safety, Fire Drills and emergency procedures. All full-time staff are up-to-date with the required training.
To make certain the associated citation does not recur, WES have implemented a plan in which the facility director will be responsible to ensure all Fee-for-service contractors be train within their 1st 30 days as well. The facility director will oversee that each contractor will have their individualized training plan completed within the first week of their start date. Included on their training plan will be the CBH Annual Training which includes fire safety/prevention, fire drills, emergency services/disaster training, crisis management, Infection control: Universal Precautions & Blood Borne Pathogens. CBH Annual training for contractors will be offered monthly. Contractors will be scheduled for the monthly training following their start date.
Employees #1 and #2 are scheduled for the next CBH Annual training in April 2016. Upon completion, their Training certificates will be placed in their contractor training file.
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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 a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies, in two of seven personnel records reviewed.
The findings include:
Five records requiring documentation that personnel on all shifts were trained to perform assigned tasks during emergencies, were reviewed on January 4, 2016.
Employee # 1 was hired on August 31, 2015. The facility failed to document the completion of training for assigned tasks during emergencies.
Employee #2 was hired on February 4, 2015. The facility failed to document the completion of training for assigned tasks during emergencies.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each new full-time staff member are required to attend new employee orientation within the 1st month of employment, which includes Fire Safety, Fire Drills and emergency procedures. All full-time staff are up-to-date with the required training.
To make certain the associated citation does not recur, WES have implemented a plan in which the facility director will be responsible to ensure all Fee-for-service contractors be train within their 1st 30 days as well. The facility director will oversee that each contractor will have their individualized training plan completed within the first week of their start date. Included on their training plan will be the CBH Annual Training which includes fire safety/prevention, fire drills, emergency services/disaster training, crisis management, Infection control: Universal Precautions & Blood Borne Pathogens. CBH Annual training for contractors will be offered monthly. Contractors will be scheduled for the monthly training following their start date.
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Employees #1 and #2 are scheduled for the next CBH Annual training in April 2016. Upon completion, their Training certificates will be placed in their contractor training file.
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