INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 2-3, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family A.C.T.S. 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 July 3, 2009.
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Plan of Correction
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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.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of the fire extinguisher within seven days of employment, in one of one personnel records.
The findings include:
Four personnel records were reviewed on June 2, 2009. One personnel record required fire extinguisher training. The facility failed to document the completion of fire extinguisher training within seven days of employment in personnel record # 4.
Employee # 4 was hired on February 17, 2009. Employee # 4 did not have documentation of the required fire extinguisher training until April 15, 2009.
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Plan of Correction
Facility Director will add fire safety training to employee orientation and document the completion of said training within the seven day time frame. |
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.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies within seven days of employment, in one of one personnel records.
The findings include:
Four personnel records were reviewed. One personnel record required the completion of emergency training. The facility failed to document the completion of emergency training within seven days of employment in personnel record # 4.
Employee # 4 was hired on February 17, 2009. Employee # 4 did not have documentation of the required emergency training until April 15, 2009.
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Plan of Correction
Facility Director will add emergency training to employee orientation and document completion of training within the required seven day time frame. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document goals with timeframes in the aftercare plan in one of one client records.
The findings include:
Five client records were reviewed on June 3, 2009. Aftercare plans were required in one client record. The facility did not document goals with timeframes in the aftercare plan in client records #5.
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Plan of Correction
Facility Director will ensure all client records will contain an appropraite aftercare plan, including but not limited to, documentation of goals with timeframes. |