INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 5, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Diakon Lutheran Social Ministries 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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705.28 (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 the review of personnel records, the facility failed to document fire extinguisher training upon staff employment.
The findings include:
Five personnel records were reviewed on June 3, 2013. One record was reviewed to verify that staff had been instructed in the use of a fire extinguisher upon employment. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel record # 4.
Employee # 4 was hired on 3/19/2013. Fire extinguisher training was due upon hire. The facility failed to documented fire extinguisher training until 4/17/2013.
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Plan of Correction
Preparation and submission of this plan of correction is required by State and Federal Law. This Plan of Correction does not constitiute admission for purposes of gereral liability, professional malpractice or any other court proceeding.
The Clinical Director/designee will ensure all new employees will be instructed in the use of fire extinguishers within the first week of hire.
Documentation of completed instruction will be kept in te employee file.
Any identified issues will be addressed by the Executive Director as appropriate. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill records, the facility failed to conduct unannounced fire drills at least once per month in six of eight months reviewed.
The findings include:
The fire drill record were reviewed on June 5, 2013. There was no documentation of unannounced fire drills for the months of October 2012, November 2012, December 2012, January 2013, February 2013 and March 2013.
Documentation in the fire drill record indicated that even though the facility received their license on October 12, 2012, they did not admit their first client until April 2013. Therefore they did not complete fire drills until April 2013.
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Plan of Correction
The lack of fire drills during the period when there were no clients cannot be corrected retroactively.
Fire drills have been conducted monthly since the program has begun serving clients and will continue as required.
The Clinical Director/designee will insure drills are conducted monthly.
Any identified issues will be addressed by the Executive Director as appropriate. |
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 the review of personnel records, the facility failed to document that all personnel were trained to perform assigned tasks during emergencies upon staff employment.
The findings include:
Five personnel records were reviewed on June 3, 2013. One personnel record was reviewed to verify that staff had been trained to perform assigned tasks during emergencies upon employment. The facility failed to document the completion of training to perform assigned tasks during emergencies upon staff employment in personnel record# 4.
Employee # 4 was hired on 3/19/2013. Training to perform assigned tasks during emergencies was due upon hire. The facility failed to document this training until 4/17/2013.
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Plan of Correction
The Clinical Director/designee will ensure that all clinicans are trained on their assigned responsibilities during emergencies upon hire.
Any idenified issues will be addressed by the Executive Director as appropriate. |