Observations
Based on a review of the facility's staff schedule work hours and CPR certification cards, the facility failed to provide a sufficient number of staff persons trained in CPR, so that at least one person trained in these skills was onsite during the project's hours of operation.
The findings include:
The staff schedule work hours for March and April 2015 and CPR certification cards were reviewed on April 21-22, 2015. The program is a 24 hour residential facility. There was no documentation that a sufficient number of staff persons trained in CPR were onsite during the project's hours of operation for the weeks March 21, 28, April 4, and 11, and April 18, 19 and 20, 2015.
Employees # 3 and 4 were hired as clinical technicians. Employees # 3 and 4 had documentation of a completed CPR certification that had been taken as an online course provided by PROCPR. There was no documentation that the CPR certification course included hands on instruction. Therefore:
There was no CPR coverage documented for March 21, 2015 from 4 PM to 12 AM.
There was no CPR coverage documented for March 22, 2015 from 12 AM to 8 AM.
There was no CPR coverage documented for March 23, 2015 from 12 AM to 8 AM and 4 PM to 12 AM.
There was no CPR coverage documented for March 24, 2015 from 12 AM to 8 AM.
There was no CPR coverage documented for March 25, 2015 from 12 AM to 8 AM
There was no CPR coverage documented for March 26, 2015- from 12 AM to 8 AM
There was no CPR coverage documented for March 27, 2015 from 12 AM to 8 AM
There was no CPR coverage documented for March 28, 2015 from 12 AM to 8 AM and 8 AM to 4 PM
There was no CPR coverage documented for March 29, 2015 from 12 AM to 8 AM and 8 AM to 4 PM
There was no CPR coverage documented for March 30, 2015 from 12 AM to 8 AM and 4 PM to 12 AM.
There was no CPR coverage documented for March 31, 2015 from 12 AM to 8 AM
There was no CPR coverage documented for April 1, 2015 from 12 AM to 8 AM and 4 PM to 12 AM.
There was no CPR coverage documented for April 5, 2015 from 8 AM to 4 PM and 4 PM to 12 AM.
There was no CPR coverage documented for April 6, 2015 from 4 PM to 12 AM.
There was no CPR coverage documented for April 7, 2015 from 4 PM to 12 AM.
There was no CPR coverage documented for April 8, 2015 from 12 AM to 8 AM.
There was no CPR coverage documented for April 9, 2015 from 4 PM to 12 AM.
There was no CPR coverage documented for April 10, 2015 from 12 AM to 8 AM and 4 PM to 12 AM
There was no CPR coverage documented for April 11, 2015 from 12 AM to 8 AM and 4 PM to 12 AM.
There was no CPR coverage documented for April 12, 2015 from 12 AM to 8 AM and 4 PM to 12 AM.
There was no CPR coverage documented for April 13, 2015 from 12 AM to 8 AM.
There was no CPR coverage documented for April 14, 2015 from 4 PM to 12 AM.
There was no CPR coverage documented for April 15, 2015 from 12 AM to 8 AM and 4 PM to 12 AM.
There was no CPR coverage documented for April 16, 2015 from 12 AM to 8 AM and 4 PM to 12 AM.
There was no CPR coverage documented for April 17, 2015 from 12 AM to 8 AM.
There was no CPR coverage documented for April 18, 2015 from 12 AM to 8 AM and 8 AM to 4 PM.
There was no CPR coverage documented for April 19, 2015 from 12 AM to 8 AM and 8 AM to 4 PM.
There was no CPR coverage documented for April 20, 2015 from 12 AM to 8 AM.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 30 all residential employees that had completed training for CPR on line were trained by Noga Ambulance Service. From the time of the state citation the above mentioned staff did not work alone on shifts. The house manager and the corporate compliance officer will assure that all employees complete the necessary training required by the state regulations. The corporate compliance and the house manager will maintain a spread sheet with all the dates and training facilities and that they are approved by the state guidelines. |
Observations
Based on a physical plant inspection, the facility failed to maintain a portable fire extinguisher with a minimum of an ABC rating that was wall mounted.
The findings include:
A physical plant inspection was conducted on April 22, 2015. The fire extinguisher, located in the kitchen, was sitting on the counter top. The fire extinguisher was not wall mounted.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 24 the house manager contacted the AAA fire company who came to the Highland Ave address on April 27 and mounted the fire extinguisher onto the wall in the kitchen. Checking of proper placement of the fire extinguishers on the wall will become part of the nightly safety walks by the clinical technicians on May 21. They will check to assure that all extinguishers are mounted correctly. The house manager will check the safety check lists each week for any violations. |