INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 15, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County 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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705.28 (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 instruct staff in the use of the fire extinguisher upon staff employment in two of three applicable records reviewed.
Staff #2 was hired on April 3, 2023 and still a current employee has not been trained on the use of fire extinguishers as of the date of onsite inspection.
Staff #5 was hired on August 28, 2023 and still a current employee has not been trained on the use of fire extinguishers as of the date of onsite inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 24, 2023 annual licensing inspection.
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Plan of Correction
During the orientation process with the human resource department, new staff will complete the fire extinguisher training on first day of employment and it will be documented in the employee's record. Facility Director will follow up affirming the fire extinguisher training has been completed.
Staff #2 who is still a current employee has completed the fire extinguisher training conducted by the human resource department director and it has been documented in employee's record. The date completed is reflected in the Corrective Action Date. |
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 are trained to perform assigned tasks during emergencies in two of three applicable records reviewed.
Staff #2 was hired on April 3, 2023 and still a current employee has not been trained to perform assigned tasks during emergencies as of the date of onsite inspection.
Staff #5 was hired on August 28, 2023 and still a current employee has not been trained to perform assigned tasks during emergencies as of the date of onsite inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 24, 2023 annual licensing inspection.
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Plan of Correction
During the orientation process with the human resource department, new staff will be trained to perform all tasks during emergencies on the new employee's first day of employment. The completed training will be documented in the employee's record. Facility Director will follow up confirming assigned tasks emergency training has been completed.
Staff #2 and Staff #5 who are still current employees and both have been trained to perform assigned tasks during emergencies by the human resource department director and it has been documented in their employee's records. The date completed is reflected in the Corrective Action Date. |