INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25-26, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Libertae Family House Libertae, Inc. 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 July 24, 2009.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of administrative documentation, the facility failed to ensure all staff had completed the HIV/AIDS and/or tuberculosis and sexually transmitted diseases training for three of twenty one staff.
The findings include:
Staff training documentation was reviewed on June 23, 2009. Twenty one staff were required to have the two mandated health related trainings.
Staff # 12 was hired April 17, 2007 and was required to have the two training sessions by April 17, 2009. There was no documentation of the employee having had the 4 hours training of tuberculosis, sexually transmitted diseases and other health related topics as of June 23, 2009.
Staff # 14 was hired May 9, 2006 and was required to have the two training sessions by May 9, 2008. There was no documentation of the employee having had the 4 hours training of tuberculosis, sexually transmitted diseases and other health related topics as of June 23, 2009.
Staff # 16 was hired January 16, 2007 and was to have the two training sessions by January 16, 2009. The documentation presented for review only demonstrated 2 hours of training of tuberculosis, sexually transmitted diseases and other health related topics as of June 23, 2009.
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Plan of Correction
Staff #12 and Staff #14 will complete Tuberculosis and sexually transmitted diseases training when the trainings become available prior to 11/14/09. This training will be conducted by the PA Department of Health or by in-house staff who has attended a D/A licensing curricula training.
Staff #16 had completed the TB/STD trainings previously; the certificate is not in her personnel file. Staff #16 is attempting to locate the certificate if it is not produced then Staff #16 will attend the TB/STD training prior to 11/14/09.
The Clinical Director will monitor these three staff to ensure the trainings are completed by 11/14/09.
Clinical Director and middle managers are collaborating to develop a AT-A-Glance tracking system in the Libertae share folder to track the due dates and the completion of mandatory trainings. This process will be reviewed on a quarterly basis following their hire date until the course is completed.
Date of Completion 11/14/2009
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
A review of the fire drill log was conducted on June 26, 2009. Documentation of a fire drill conducted during sleeping hours is required once every six months. The facility documented a drill during sleeping hours on 11-17-08 and again on 6-4-09, more than six months apart.
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Plan of Correction
Responsible Party: Operations Manager
A fire drill was conducted during sleeping hours on 7/27/09 at 4 a.m.
At the Treatment Tech Meeting on 8/17/09 there was a thorough training on fire drill documentation.
The Operation Manager will ensure that fire drills will be conducted during sleeping hours at a minimum of every 6 months. The Operations Manager will review fire drill logs on a monthly basis to ensure accuracy.
The fire drill documentation will be revised to clarify times and exits.
To be completed by 8/17/09.
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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of administrative documentation, the facility failed to document which exit routes were used in seven of thirteen fire drills recorded.
The findings include:
Administrative documentation that included the binder of recorded fire drills was reviewed on June 26, 2009. There was no documentation of an exit route used on 8-15-08; 2-17-09; 3-19-09; 4-19-09; 5-14-09; 6-4-09; 6-19-09.
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Plan of Correction
Responsible Party: Operations Manager
An overnight drill was conducted on 7/27/09 at 4 a.m.
The facility will assure that fire drills will happen during sleeping hours at a minimum of every 6 months.
The Operations Manager will review the fire drill schedule on a monthly basis.
During the Treatment Tech Meeting on 8/17/09 there was a thorough training on fire drill documentation.
The fire drill documentation was revised on 8/17/09 to clarify times and exits. |