INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 18, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Ellen O'Brien Gaiser Addiction 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.
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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 one of one personnel records.
The findings include:
Five personnel records were reviewed on June 18, 2014. One employee was a new hire and was required to received instruction in the use of the fire extinguisher upon employment. The facility failed to instruct staff in the use of the fire extinguisher upon staff employment in personnel record # 3.
Employee # 3 was hired on July 22, 2013. Fire extinguisher training was not documented for employee # 3 until December 11, 2013. The facility failed to instruct staff in the use of the fire extinguisher upon employment.
The findings were confirmed by the human resources administrative staff on June 18, 2014.
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Plan of Correction
Effective 6/18/14 the Human Resource Administrator will instruct all staff in the use of the Fire Extinguisher upon Employment and will document this accordingly. The Gaiser Center already had a process in place for this and will make sure that no future instances occur that this instruction is not documented correctly. The Human Resource Administrator will ensure all new staff are trained in the use of the fire extinguisher within 7 days of hire. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
Fire drill records for July 2013 through May 2014 were reviewed on June 18, 2014. No fire drills were conducted from July 2013 through February 2014. The facility failed to conducted unannounced fire drills at least once a month.
The project/facility director confirmed the findings on June 18, 2014.
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Plan of Correction
Effective March 1, 2014 the Gaiser Center implemented a plan and assigned the responsibility of implementation to the Outpatient Intake Coordinator and oversight of all fire drills to the Gaiser Center Facility Manager. Monthly fire drills have been conducted and documented since this date and will continue to be done on a monthly basis. |