INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on 12-8-2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Community Services Foundation Woodlyn 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(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of facility staff CPR/first aid certification cards, the facility failed to ensure that at least one person trained in CPR skills onsite during the project's hours of operation. The findings include: Based on a review of staff schedules and staff CPR/first aid certification cards, the facility failed to have sufficient amount of staff trained in these skills on duty. After a conversation with the program coordinator, it was confirmed only one staff member per facility has the CPR/first aid qualification.
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Plan of Correction
Each facility has one CPR/first aid current certified person trained. By April 1, 2012 the executive director and clinical supervisor will ensure that additional staff are certified to ensure that at lease two staff are certifed at the facility for each day, in case of a staff absence another staff person is certified. The executive director has already scheduled the CPR/first aid training and will continue certification trainings annually to keep certifications current. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a review of the physical plant, the facility failed to be free of hazard for the well being of clients.The findings include;A physical plant inspection was conducted on December 8, 2011. The front entry doorway had a floor mat on the floor that was curled up on the edges, creating a hazard to the clients, staff and visitors using this area to enter the building. The counselor removed the mat immediately upon request.
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Plan of Correction
This rug has already been removed. The project director will ensure that staff are trained on safe entry ways for staff and clients by 1/15/12. |
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 record log, the facility failed to document two monthly fire drills. The findings include: The fire drill record log was reviewed on December 8, 2011. The log was reviewed from December 2010 to November 2011. Two of those twelve months did not document that a fire drill was conducted. July 2011 and August 2011 were the two months that that the facility did not document fire drills. This was confirmed with the program coordinator/clinical supervisor on December 8, 2011.
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Plan of Correction
There were no clients at this facility during these months. Since the partial program and outpatient program had no clients at this facility durning the summer months, no fire drills were conducted. The Project Director will ensure that fire drills will be conducted at the facilities during the summer months whether clients are in attendance or not. All licensed facilities will conduct monthly fire drills throughout the year. |