INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 8, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Caron Outpatient Services LLC 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of five personnel files, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in one of one applicable record reviewed.
Employee # 1 was hired as the Project Director on September 29, 2023 and was due to be trained in the use of fire extinguishers upon hire; however, fire safety training was not documented as completed in the personnel record until October 12, 2023.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Currently, all new employees receive training on fire safety emergency procedures, as well as fire extinguisher training with their supervisor on the first day of employment. The new employee signs an attestation indicating they received the training, which is filed in their employee file.
In order to improve upon this process a plan is in place where the Human Resources Business Partners will electronically send new employees training on fire safety emergency procedures, as well as training and instruction on how to use
fire extinguishers prior to their first day of employment. Employees must sign an attestation indicating that they received this training and must return this attestation to the training department by their first day of employment. This attestation will be kept in their training file. The Supervisor of Training and Education will audit new employee files on a monthly basis to ensure compliance with this regulation. The new process is expected to be implemented by 3/1/24.
|
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.
|
Observations
Based on a review of five personnel records, the facility failed to ensure that one of one applicable staff member was trained to perform assigned tasks during emergencies prior to being on shift.
Employee # 1 was hired as the Project Director on September 29, 2023 and is current in that position. Employee # 1 began working shifts on September 29, 2023, but was not trained to perform assigned tasks during emergencies until October 12, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Currently, all new employees receive training on fire safety emergency procedures, as well as fire extinguisher training with their supervisor on the first day of employment. The new employee signs an attestation indicating they received the training, which is filed in their employee file.
In order to improve upon this process a plan is in place where the Human Resources Business Partners will electronically send new employees training on fire safety emergency procedures, as well as training and instruction on how to use
fire extinguishers prior to their first day of employment. Employees must sign an attestation indicating that they received this training and must return this attestation to the training department by their first day of employment. This attestation will be kept in their training file. The Supervisor of Training and Education will audit new employee files on a monthly basis to ensure compliance with this regulation. The new process is expected to be implemented by 3/1/24.
|
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom disclosure is made on consent to release information forms in one of eight client records reviewed.
Client # 1 was admitted on May 23, 2023 and was discharged on August 29, 2023. The release of information form to the funding source was signed and dated by the client on May 24, 2023; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Lead Health Records Management Specialist will facilitate a Privacy and Confidentiality Refresher Training for Plymouth Meeting staff on 2/5/24. This training will include education about the required elements of a Release of Information form, including the name of the person, agency or organization to whom the disclosure is made. The Senior Director of Health Records Management will audit records on a weekly basis and report progress to site leadership to ensure compliance of this regulation. |