INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 an interview with the Facility Director, the facility failed to ensure that CPR and First Aid certification was provided to a sufficient number of staff persons, so that at least one person trained in these skills was onsite during the project's hours of operation.
The findings include:
On March 24, 2016, copies of staff CPR and First Aid certification were requested. The facility was unable to provide documentation of CPR and First Aid certification as none of the four listed facility staff are certified in either CPR and First Aid certification.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Both the Facility Director and Clinical Supervisor will be trained in CPR and First Aid. On a weekly basis, the Project Director will monitor the hours of operations of the project and staff work schedules to ensure that sufficient staff are trained in CPR and First Aid so that at least one person trained in CPR and First Aid is on site during the project's hours of operations.
Completion Date: April 28, 2016.
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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 a review of personnel records, the facility failed to provide documentation of fire extinguisher training upon staff employment.
The findings include:
Two personnel records were reviewed on March 24, 2016, to verify that staff had been instructed in the use of a fire extinguisher upon employment. The facility failed to provide documentation to verify that employees #1 and 3 had completed fire extinguisher training upon employment.
Employee # 1 was hired on May 18, 2015. The facility failed to provide documentation that employee # 1 received fire extinguisher training upon hire.
Employee # 3 was hired on January 4, 2016. The facility failed to provide documentation that employee # 3 received fire extinguisher training upon hire.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director was trained in fire safety and the use of fire extinguisher on April 11, 2016. The Facility Director will schedule and monitor the completion of fire safety and the use of fire extinguisher training of current staff assigned to the project. The Facility Director will monitor to ensure that all new staff hired for the project will complete fire safety and fire extinguisher training during the initial agency orientation. The Facility Director will verify by review of Personnel Chart maintained in Holcomb Behavioral Health Systems Human Resources that this training was completed prior to the Completion Date for current staff and at the time of hire during the initial agency orientation for newly hired project staff.
Completion Date: May 26, 2016.
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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 facility's fire drill log, the facility failed to conduct unannounced fire drills at least once a month; ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies; and set off a fire alarm or smoke detector during each fire drill.
The findings include:
On March 24, 2016, the facility's fire drill log was reviewed covering the period of April 2015 until February 2016.
1. The facility failed to failed to conduct unannounced fire drills during the month of May 2015, June 2015, and July 2015.
2. The facility failed to set off a fire alarm or smoke detector during each monthly fire drill.
Additionally, the facility failed to provide documentation that employees # 1 and 3 were trained to perform assigned tasks during emergencies.
Employee # 1 was hired on May 18, 2015. The facility failed to provide documentation that employee # 1 was trained to perform assigned tasks during emergencies.
Employee # 3 was hired on January 4, 2016. The facility failed to provide documentation that employee # 3 was trained to perform assigned tasks during emergencies.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Fire drills will be performed and documented that they were performed each month. The Facility Director will meet with the Environment of Care (EOC) committee respresentative for the Pottstown location 1X per month to ensure that this standard is being met.
A fire alarm will be set off during each fire drill. Thjis will be documented by the EOC committee representative, and the Facility Director will meet with the EOC representative 1X per month to ensure that this standard is being met.
The Facility Director will provide training to all current project staff to ensure that they are aware of and know how to perform assigned tasks during emergencies within 1 month of acceptance of the COP. All newly hired staff for the project will receive this training at the time of hire. Documentation of this training will be kept in each employee's respective personnel training file. |