INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 27 - 28, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mon Yough Community Services, 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.
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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 a review of personnel training records, the facility failed to document the instruction of staff in the use of the fire extinguisher upon staff employment, in two of four personnel records.
The findings include:
Eight personnel training records were reviewed on August 27, 2012. Four personnel records were reviewed for documentation of fire extinguisher training. The facility failed to document fire extinguisher training upon staff employment in personnel training records # 4 and 5.
Employee # 4 was hired on February 22, 2012. Employee # 4 did not complete fire extinguisher training until April 9, 2012. The facility failed to instruct staff on the use of the fire extinguisher upon employment.
Employee # 5 was hired on February 29, 2012. Employee # 5 did not complete fire extinguisher training until March 23, 2012. The facility failed to instruct staff on the use of the fire extinguisher upon employment.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Plan of Correction
Four staff personnel training records were reviewed. All 4 staff did completed fire extinguisher training however 2 staff were not completed within seven days of employment. Effective October 1, 2012, the Facility Director will assure documentation of training to instruct staff on the use of fire extinguishers no later than seven days from the date of employment.
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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 a review of personnel training records, the facility failed to document that all personnel on all shifts were trained upon employment to perform assigned tasks during emergencies in three of four personnel records.
The findings include:
Eight personnel training records were reviewed on August 27, 2012. Four personnel records were reviewed for documentation of emergency training. The facility failed to document that all personnel were trained upon employment to perform assigned tasks during emergencies in personnel training records # 4, 6 and 7.
Employee # 4 was hired on February 22, 2012. Employee # 4 did not complete emergency training until March 9, 2012.
Employee # 6 was hired on May 1, 2012. Employee # 6 did not complete emergency training until August 6, 2012.
Employee # 7 was hired on June 10, 2012. Employee # 7 did not complete emergency training until August 2, 2012.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Plan of Correction
Eight staff training records were reviewed. All staff did complete training regarding assigned tasks during emergencies. Three staff records failed to document that all personnel were trained upon employment to perform assigned tasks during emergencies within seven days of employment. Effective October 1, 2012, the Facility Director will assure staff are provided training upon employment to perform assigned tasks during emergencies no later than seven days from the date of employment.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to maintain a fire drill record that included the exit route used during monthly fire drills.
The findings include:
Fire drill records were reviewed on August 27, 2012. The facility failed to document the exit route used during the following monthly fire drills: October 13, 2011, November 17, 2011, December 19, 2011, January 23, 2012, February 28, 2012, March 30, 2012, April 11, 2012, May 31, 2012, June 26, 2012, July 27, 2012 and August 24, 2012.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Plan of Correction
Monthly fire drills were completed however the new fire drill form which was implemented October 2011 did not include exit route. Effective October 1, 2012, the Facility Director will assure the fire drill form will be revised to include exit route.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill records for October 2011 through August 2012 were reviewed on August 27, 2012. The exit route used was not documented for the fire drills conducted on the following dates: October 13, 2011, November 17, 2011, December 19, 2011, January 23, 2012, February 28, 2012, March 30, 2012, April 11, 2012, May 31, 2012, June 26, 2012, July 27, 2012 and August 24, 2012. It is not possible to determine if alternate exit routes were utilized during these monthly fire drills. The facility failed to document the use of any alternate exits during monthly fire drills.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Plan of Correction
Monthly fire drills were completed however the new fire drill form which was implemented October 2011 did not include exit route therefore it was not possible to determine if alternate exit routes were utilized during these monthly fire drills. Effective October 1, 2012, the Facility Director will assure the fire drill form is revised and documents the use of any alternate exits during the monthly fire drill.
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709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
Based on a review of the policy and procedure manual and personnel records, the facility failed to document written policies on employee rights and demonstrate the project's efforts toward informing staff of the employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records in five of five personnel records.
The findings include:
The policy and procedure manual was reviewed on August 27, 2012. The facility failed to document a written policy on the employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records. Eight personnel records were reviewed on August 27, 2012. Five personnel records pertained to new employees and required documentation that the employee was informed of the right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records. The facility failed to inform employees # 4, 5, 6, 7 and 8 of the right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
Employee # 4 was hired by the facility on February 22, 2012. Employee # 4 was provided a copy of the personnel policies and procedures. The personnel policies and procedures did not include the right of the employee to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
Employee # 5 was hired by the facility on February 29, 2012. Employee # 5 was provided a copy of the personnel policies and procedures. The personnel policies and procedures did not include the right of the employee to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
Employee # 6 was hired by the facility on May 1, 2012. Employee # 6 was provided a copy of the personnel policies and procedures. The personnel policies and procedures did not include the right of the employee to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
Employee # 7 was hired by the facility on June 10, 2012. Employee # 7 was provided a copy of the personnel policies and procedures. The personnel policies and procedures did not include the right of the employee to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
Employee # 8 was hired by the facility on December 28, 2011. Employee # 8 was provided a copy of the personnel policies and procedures. The personnel policies and procedures did not include the right of the employee to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the September 21 - 22, 2011 licensing inspection.
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Plan of Correction
Plan of Correction
Facility Director will assure MYCS will include the below information in the staff record policy section of MYCS Policy and Procedure by January 4, 2013. The employee's have a right to request the correction or removal of inaccurate, irrelevant outdated or incomplete information from the records. Employee must schedule an appointment with human resources 48 hours in advance. Employee may review their file within the confines of the human resources department. Staff will be informed of the revision via electronic notice.
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709.26(e)(3) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(3) The employe's right to submit rebuttal data or memoranda to his own records.
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Observations
Based on a review of the policy and procedure manual and personnel records, the facility failed to document written policies on employee rights and demonstrate the project's efforts toward informing staff of the employee's right to submit rebuttal data or memoranda to his own records in one of one personnel records.
The findings include:
The policy and procedure manual was reviewed on August 27, 2012. The facility failed to document a written policy on the employee's right to submit rebuttal data or memoranda to his own records, as required by regulation. Eight personnel records were reviewed on August 27, 2012. Five personnel records pertained to new employees and required documentation that the employee was informed of the right to submit rebuttal data or memoranda to his own records. . The facility failed to inform employees # 4, 5, 6, 7 and 8 of the right to submit rebuttal data or memoranda to his own records.
Employee # 4 was hired by the facility on February 22, 2012. Employee # 4 was provided a copy of the personnel policies and procedures. The personnel policies and procedures did not include the right of the employee to submit rebuttal data or memoranda to his own records.
Employee # 5 was hired by the facility on February 29, 2012. Employee # 5 was provided a copy of the personnel policies and procedures. The personnel policies and procedures did not include the right of the employee to submit rebuttal data or memoranda to his own records.
Employee # 6 was hired by the facility on May 1, 2012. Employee # 6 was provided a copy of the personnel policies and procedures. The personnel policies and procedures did not include the right of the employee to submit rebuttal data or memoranda to his own records.
Employee # 7 was hired by the facility on June 10, 2012. Employee # 7 was provided a copy of the personnel policies and procedures. The personnel policies and procedures did not include the right of the employee to submit rebuttal data or memoranda to his own records.
Employee # 8 was hired by the facility on December 28, 2011. Employee # 8 was provided a copy of the personnel policies and procedures. The personnel policies and procedures did not include the right of the employee to submit rebuttal data or memoranda to his own records.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the September 21 - 22, 2011 licensing inspection.
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Plan of Correction
Plan of Correction
Facility Director will assure MYCS will include the below information in the staff record policy section of MYCS Policy and Procedure by January 4, 2013. The employee's have the right to submit rebuttal data or memoranda to his/her own record. Employee must schedule an appointment with human resources 48 hours in advance. Employee may review their file within the confines of the human resources department. Staff will be informed of the revision via electronic notice.
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