INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, 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:
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Plan of Correction
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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.
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Observations
Based on a review of personnel records and the Staffing Requirement Facility Summary Report, the facility failed to ensure a sufficient number of staff persons were certified in CPR and trained in first aid during the project's hours of operation.
There were only two employees listed for this location and documentation of employee #1's CPR certification and first aid training was provided. However, employee #1 had no reported hours worked at this facility per week. Employee #2 was the only staff member with hours reported at this location and documentation was provided for employee #2's first aid training. However, there was no documentation provided for employee #1's CPR certification.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Regional Director has signed up for CPR training and will take training and become recertified on 5/21/24.
CPR certificate will be provided to DDAP upon receipt. |