INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 23, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Good Works Life Recovery House 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(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of personnel training documentation, the facility failed to document an assessment of staff training needs and an overall plan for addressing the needs.The findings include:The facility's personnel training documentation was requested on December 23, 2013. The facility currently only employs a project / facility director. The facility failed to document a training assessment or a training plan for the project / facility director.The findings were discussed with the project / facility director and were not disputed.
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Plan of Correction
Since becoming aware of this issue, the Program Director has completed a self assessment indicating the type of training that she feels is needed to enhance her administrative skills and knowledge. A training plan was formulated using the results of the assessment. A copy of the training plan can be found in the Program Director's Personnel File and is available for review. This POC was finalized on 2/11/14. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.The findings include:A physical plant inspection was conducted on December 23, 2013 at approximately 12:30 PM. The two fire extinguishers mounted within the facility were last inspected in June 2012 by a local fire extinguisher company.The findings were discussed with the facility owners and were not disputed.
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Plan of Correction
The facilitiy's fire extinguishers have been inspected and approved by Safety First Fire Equipment. This correction took place on 1/24/2013. The building owners have agreed to being responsible for future timely inspections, as the extinguishers are required by their property insurance carrier. The Administrative Assistant hired will be responsible for ensuring that the said property owners have completed the task at least two weeks prior to the expiration date tagged on the extinguishers. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's fire drill log, the facility failed to conduct unannounced fire drills at least once a month in seven of seven months reviewed.The findings include:The facility has been licensed since May 24, 2013. The facility's fire drill log for the time frame of May 2013 to November 2013 was reviewed on December 23, 2013. The facility failed to conduct fire drills for the months of May, June, July, August, September, October and November 2013.The facility owner confirmed that no fire drills have been conducted since May 24, 2013.
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Plan of Correction
Fire drills will be held a minimum of once a month. The Counselor Assistant has agreed to take responsibility for conducting and documenting the fire drills until the time the facility becomes operational and fully staffed. At that time, the Administrative Assistant will be responsible for overseeing that a support staff person from all three shifts, conduct a minimum of one fire drill per month and documenting it in the fire drill log. Fire drills will be conducted at various times during the day and night. The first fire drill was conducted and documented on 2/1/2014 and will be a minimum of one time per month moving forward. |