INITIAL COMMENTS
|
This report is a result of an on-site licensing inspection conducted on, December 7, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Community Service Foundation, Inc.of Feasterville 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.
|
Plan of Correction
|
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.
|
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. Findings: Based on a review of staff schedules and staff CPR/first aid certification cards, the facility failed to have any staff trained in these skills on duty. Only one staff was trained to provide this service.
|
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. |
705.28 (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.
|
Observations
Based on a review of the fire drill record log, the facility failed to document fire drills at least monthly. The findings include: The fire drill record log was reviewed on December 12, 2011. The log was reviewed from December 2010 to November 2011. The facility failed to provide documentation that fire drills were conducted in June 2011, July 2011 and August 2011.This finding was confirmed with administrative staff and not disputed..
|
Plan of Correction
The facility director and coordinator will train and ensure summer program staff will conduct fire drills during the summer months. The training will be completed prior to the summer in May 2012 and the coordinator will check the fire log for accurancy. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to document a supervisor's signature on the case consultations as per the facility policy. The findings include:Eight outpatient client records were reviewed on December 7, 2011. Per agency policy, case consultations were required to be signed by the counselor and the supervisor. The facility failed to have documentation that the supervisor signed six of eight client records reviewed. Client # 1 was admitted on 11-5-2010 and was discharged on 6-6-2011. The case consult was completed by the counselor on 5-5-2011. There was no signature provided by the counselor's supervisor.Client # 2 was admitted on 11-30-2010 and was discharged on 2-25-2011. The case consultation was completed by the counselor on 2-26-2011. There was no signature provided by the counselor's supervisor.Client # 4 was admitted on 8-21-2011 and the client case consult was completed on 12-02-2011 by the counselor. There was no signature provided by the counselor's supervisor.Client #6 was admitted on 11-10-2010 and was discharged on 4-11-2011. The case consultation was completed on 3-10-2011 by the counselor. There was no signature provided by the counselor's supervisor on the document.Client # 7 was admitted on 11-15-2010 and was discharged on 6-22-2011. The case consultation was completed by the client's counselor on 3-15-2011. There was no signature provided by the counselor's supervisor.Client record # 8 was admitted was admitted on 10-26-2010 and was discharged on 3-31-2011. The case consultation was completed by the counselor on 2-25-2011. There was no signature provided by the counselor's supervisor.
|
Plan of Correction
By 3/15/12, our policy and procedure manual will match our practice. The project director will ensure that the changes are made to the policy and procedure manual to accurately describe the case consultation process and signature. |