INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July10, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Diakon Family Life Services was found to not 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
The facility failed to ensure that employees used a mechanism to collect feedback on completed training based on a review of personal files.
Staff #1, #2, #3, and # 4 did not complete feedback forms for any training that they received.
These findings were reviewed with facility staff duing the licensing process.
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Plan of Correction
Training feedback form was developed and staff were trained on the procedure to provided training feedback on 7/12/18. All staff will complete training feedback following training events in accordance with regulation. |
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
The facility failed to document alternate exit routes to be used during fire drills based on review of the fire drill record.
Fire drills dated May 2017 through May 2018, all used the front door as the exit route during the fire drills each month.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were trained on the requirement and importance of using alternative exit routes during fire drills on 7/12/18. Fire drills will alter exit routes according to regulation. |