INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 25 - 26, 2008, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Sojourner House, 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 April 21, 2008.
|
Plan of Correction
|
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of the personnel and training records on March 25 and 26, 2008, the facility failed to provide fire extinguisher training to new employees within seven days of the date of hire. This lapse was noted in four of six personnel records reviewed. Specifically, documentation in personnel records #1, 4, 6, 7 demonstrated that the training was not provided until more than seven days from the hire date.
|
Plan of Correction
705.10 (c)(4)Fire Safety: Effective 4/1/2008, all new employees receive training in the use of fire extinquishers within 7 days of hire. The Director of Finance & Operations is responsible for new employee orientation that includes compliance with fire extinquisher training. The Executive Director will provide oversight to insure 100% compliance. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of the personnel and training records on March 25 and 26, 2008, the facility failed to provide the emergency preparedness training to new employees within seven days of employment. Four of six personnel records reviewed demonstrated that the training was provided more than seven days from the date of hire. Refer to personnel records #1, 4, 6, 7.
|
Plan of Correction
Effective 4/1/2008, all new staff will receive emergency preparedness training within 7 days of employment. Training will be facilitated by the Director of Finance & Operations. The Executive Director will provide oversight to insure compliance with ermergency preparedness training. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on client record reviews on March 26, 2008, the facility failed to provide a review of the client's progress relative to the treatment plan goals and objectives on the treatment plan update. This lapse was noted in two of three client records. Refer to client records # 1 and 2.
|
Plan of Correction
709.52 Treatment & rehabilitation services (b)
Effective 4/1/2008, treatment plan reviews will include the review of clients progress relative to the treatment goals and objectives. All progress will be documented on the treatment plan update. Treatment plans are reviewed and updated at least every 30 days. The Clinical Supervisor is responsible to insure compliance. |