INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 19 - 21, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cornell Abraxas I 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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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 fire drill records, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
Fire drill records were reviewed for March 2011 through February 2012 on March 20, 2012. The facility has four dormitories for residential clients. Two of the four dormitories failed to conduct monthly unannounced fire drills.
The facility failed to document unannounced fire drills at the Dakota dormitory for the months of November 2011 and January 2012.
The facility also failed to document fire drills at the Mountain Top dormitory for the months of November 2011 and February 2012.
The Quality and Compliance Specialist was interviewed on March 20, 2011, at approximately 12:40 PM and confirmed the findings.
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Plan of Correction
The Maintenance Supervisor had identified the missing drills for January and February 2012. He had additional drills conducted in Dakota and Mountain Top dorms in March.
The Maintenance Supervisor reviewed the documentation which outlines the months in which a fire drill should be conducted in each dorm. He noted issues with the scheduling of second shift drills. He met with the Program Manager and identified a plan to ensure the fire drills, particularly those on second shift, will be conducted as needed.
The on-duty supervisor will be assigned to conduct the second shift drill in the dorms once per quarter. The maintenance department will be assigned to conduct the first shift drill once per quarter. The night supervisors will be assigned to conduct the third shift (e.g., sleeping drills) once per quarter. The Maintenance Supervisor is responsible for monitoring the completion of all fire drills. During the third week of the month, the Maintenance Supervisor will identify any drills that were not yet held for the current month. He will work with the Program Manger to have the drills conducted during the last week of the month to ensure compliance with the requirement for monthly drills.
The Quality & Compliance Specialist will cross reference the Maintenance Supervisor's report with all documentation related to fire drills to ensure all monthly fire drills were completed. Compliance with the fire drills will be discussed with the Leadership Team during weekly Leadership Meetings and monitored monthly during Safety/Infection Control Committee Meetings.
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709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of the facility ' s policy manual and medication storage area inspection logs, the facility failed to document monthly inspections of the medication storage areas as required by agency policy.
The findings include:
The monthly medication storage area inspection logs were reviewed on March 19, 2012. Per agency policy, inspections of the medication storage areas are to be conducted monthly. There were no medication storage area inspections for the following months: August 2011, September 2011, October 2011, November 2011, December 2011 and January 2012.
The Quality and Compliance Specialist was interviewed on March 19, 2012, at approximately 3:45 PM, and confirmed the findings.
This is a repeat citation from the February 7 - 9, 2011 licensing inspection.
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Plan of Correction
On February 15, 2012, the Quality & Compliance Specialist met with all of the nurses to discuss the process and documentation requirements for medication storage area inspections. She reinforced that documented inspections need to be completed on a monthly basis. Additional meetings were held in March with new members of the Medical Department to review the process. The Medical Technician will assist the nurses with the medication storage area inspections. Inspection documentation will be submitted to the Quality & Compliance Specialist by the 5th day of the following month. The Quality & Compliance Specialist will monitor inspection documentation to ensure compliance. Findings will be discussed in the monthly Safety/Infection Control Committee meetings. |