INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 5, 2007 through September 6, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Libertae Family House 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 September 28, 2007.
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Plan of Correction
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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on the physical plant inspection on September 6, 2007, the facility failed to ensure that exits were unobstructed. The daycare exit in the basement was obstructed.
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Plan of Correction
Who is responsible: Operations Manager
What is the correction:
All exits will be unobstructed.
The correction was made immediately
Resident Managers and Treatment Technicians will monitor daily for compliance.
When will this correction take place:
9/07/07
How will staff be informed?
During the Operations Manager Department meeting protocol will be reviewed.
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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 the fire drill record, the facility failed to ensure that fire drills were conducted during sleeping hours at least every 6 months. Only one fire drill (on April 30, 2007) was conducted during sleeping hours from October 2006 through August 2007.
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Plan of Correction
Who is responsible: Operation Manager
The correction:
We will ensure that fire drills will be conducted during sleeping hours at least every 6 months
When will this correction take place:
As of 9/28/07 this plan will be activated.
How staff be informed:
During Operation Manager's regularly scheduled department meetings the staff were
informed of the schedule and trained appropriately in how to conduct the fire drills
according to state protocol. A calendar has been developed and a monthly review
at supervision with the Executive Director is now part of our protocol
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709.32(c)(2) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(2) Drug storage areas.
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Observations
Based on a review of the physical plant medication storage area conducted on September 6, 2007, the facility failed to ensure that food would not be stored in the medication refrigerator. Employee food was observed in the refrigerator designated for medication only.
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Plan of Correction
Who is responsible: Operation Manager
What is the correction:
Food will not be stored in the medication refrigerator
Resident Managers and Treatment Technicians will monitor daily to ensure compliance.
When will this correction take place:
September 7, 2007
Food was immediately removed.
How will staff be informed:
October 1, 2007 staff meeting a review of medication storage protocol will be reviewed with all staff.
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