INITIAL COMMENTS
|
This report is a result of a complaint investigation conducted on June 16, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the investigation, Davis Archway House, 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 investigation and a plan of correction is required.
|
Plan of Correction
|
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.
|
Observations
Based on a review of the staff schedules, conducted on June 16, 2020, the facility failed to ensure that at least one staff on every shift that was CPR certified.A schedule was submitted that indicated the hours worked for the residential tech staff for the period from March 1, 2020 through June 15, 2020. CPR cards were submitted and employee #1 was not CPR certified until June 3, 2020 however, he was on the third shift schedule, with no other staff on the premises, during the following time-frames:May 6, 2020: 12 am to 7 am May 11, 2020: 12 am to 7 am May 12, 2020: 12 am to 7 am May 13, 2020: 12 am to 7 am May 18, 2020: 12 am to 7 am May 19, 2020: 12 am to 7 am May 20, 2020: 12 am to 7 am May 25, 2020: 12 am to 7 am May 26, 2020: 12 am to 7 am May 27, 2020: 12 am to 7 am June 1, 2020: 12 am to 7 am June 2, 2020: 12 am to 7 am This information was reviewed with the facility staff during the investigation.
|
Plan of Correction
The Facility Director reviewed all training files for support staff and confirmed there is adequate staff trained in CPR to cover all three shifts. Going forward, the director will review all employee schedules two weeks in advance to assure at least one person per shift is CPR certified. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on a review of administrative documentation and interviews with staff and residents, conducted on June 16, 2020, the facility failed to report an incident at the facility requiring the presence of an ambulance. On May 24, 2020 an incident occurred that required a resident to be transported to the hospital, via ambulance, after a fall at the facility. This incident was not reported to the Department within 3 business days, as is required. This information was reviewed with the facility staff during the investigation.
|
Plan of Correction
The Facility Director reviewed policies with all staff regarding notification requirements and the specific time frames for submission. All incident reports shall be written and promptly given to the immediate supervisor or the Facility Director to assure timely filing with DDAP. All required incidents shall be reported within 3 days. |