INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 24, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Central Montgomery Mh/MR Center 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 and a plan of correction is due on September 24, 2010.
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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 and an interview with the project/facility director, the facility failed to document the instruction of staff in the use of the fire extinguisher upon staff employment, in one of six personnel records, as required.
The findings include:
On August 24, 2010 six personnel records were reviewed. Six employees required fire extinguisher training. Per regulation, the nonresidential facility shall instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel record # 5.
Employee # 5 was hired on January 16, 2010. As of the date of inspection, there was no documentation that employee # 5 completed fire extinguisher training.
During an interview the facility director confirmed there was no documentation of emergency training for employee #5.
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Plan of Correction
Staff #5 was instructed on the use of the fire extinguisher on 8/26/10. The Facility Director will instruct all new hires on the use of fire extinguishers and documented within seven days of the date of hire. |
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 and an interview with the project/facility director, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies.
The findings include:
On August 24, 2010 six personnel records were reviewed. Six employees required emergency training. Per regulation, the nonresidential facility shall ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies. This instruction shall be documented by the facility. The facility failed to document the completion of emergency training in personnel record # 5.
Employee # 5 was hired on January 16, 2010. As of the date of inspection, there was no documentation that employee # 5 completed emergency training.
During an interview the facility director confirmed there was no documentation of emergency training for employee #5.
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Plan of Correction
Staff #5 was instructed on fire safety and performing assigned tasks during an emergency on 8/26/10. The Facility Director will instruct all new hires on fire safety and assigned tasks during an emergency and documented within seven days of the date of hire. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of outpatient client records, the facility failed to complete an aftercare plan which includes the reentry process and a contact person in one of one client record.
The findings include:
On August 24, 2010 eight outpatient client records were reviewed. One client record was required to have documentation of an aftercare plan, specifically record # 6.
Client # 6 was admitted on December 9, 2009 and discharged on July 12, 2010. The aftercare plan was completed on July 12, 2010. The aftercare plan did not include a reentry process or the contact person for reentry.
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Plan of Correction
The aftercare plan form has been modified to include the agency's name, address, phone number, the reentry process, and the contact person for reentry. Staff will be informed of the form change and the form will be put into effect beginning 9/20/10. |
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 CPR and First Aid Training certification cards and staff schedules, the facility failed to ensure at least one person trained in First Aid is onsite during the project's hours of operation, specifically Tuesdays from 5pm -8pm.
The findings include:
On August 24, 2010 staff schedules, CPR cards, and First Aid cards were reviewed. The facility failed to furnish verification of First Aid Training for employee #7. The schedule reflects employee #7 works Tuesdays from 9am to 8pm. According to the schedule presented, employee #7 is the only staff in the facility from 5pm-8pm on Tuesdays.
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Plan of Correction
Employee #7 will be trained in First Aid on 10/4/10 through the American Red Cross. Until this training is completed, the Facility Director (employee #2) will be responsible for First Aid coverage on Tuesdays until 8 PM. The Facility Director will send a copy of the First Aid certification for employee #7 once it is obtained. The Facility Director will do annual reviews to ensure staff are renewing certification as well as to ensure there is a sufficient number of staff trained in these skills to cover the agency's hours of operation. |