INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 30-31, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Perspectives at White Deer Run 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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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of facility records conducted as part of the presubmission process, the facility failed to conduct fire drills for the months of March, September, and October of the year 2016, and the facility records document that the detox unit did not conduct a fire drill in November of the year 2016.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The clinical tech supervisor will review with all personnel responsible that we are to conduct monthly fire drills.
The clinical tech supervisor will train all new hires and retrain current employees responsible for conducting fire drills by 5/30/17. These trainings will consist of the correct way to conduct an unannounced fire drill. This includes making sure all buildings are evacuated during the drills.
The Clinical Tech supervisor will observe employees conducting unannounced fire to make sure they are completed correctly and give feedback and guidance when necessary.
The fire drills forms will be kept in a binder where they can be audited on a biweekly basis to ensure fire drills are being conducted and that fire drill forms are being filled out correctly.
The biweekly audit of the fire drill binder will ensure that we are conducting fire drills every month.
Also a reminder will be sent out at the beginning of the month by the technician supervisor to remind staff of the responsibility to conduct the fire drill.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 facility records conducted as part of the presubmission process the facility failed to document all of the required information in its fire drill logs.
The facility failed to document the exit routes used during the evacuation for fire drills held on the following days: 01/26/2017, 12/08/2016, 11/11/2016, 08/12/2016, 07/21/2016 and 06/10/2016.
The facility failed to document wether the fire alarm of smoke detector was operative during the evacuation for fire drills held on the following days: 12/08/2016, and 11/11/2016.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Clinical Technician Supervisor will train all staff that are responsible for filling out the fire drill forms by 5/30/17.
The Clinical Technician supervisor will audit these forms on within one week of the fired drill being conducted to make sure they are filled out properly which will include the following: 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of facility records conducted during the presubmission process, the facility failed to conduct a sleeping hours fire drill from March 1, 2016, through January 31, 2017.
These findings were discussed with facility staff as part of the inspection process.
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Plan of Correction
The Clinical Technician Supervisor will make sure all personnel responsible for conducting fire drills be trained on the making sure we conduct during sleeping hour's drills every six months as required by DDAP. This training will be conducted by 5/30/17
The Clinical Technician Supervisor will ensure this is happening by auditing our fire drill binder biweekly to make sure we are in compliance with the 6 month mark of sleeping hour fire drills.
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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records the facility failed to ensure that patients were properly screen prior to beginning narcotic treatment.
Patient #2 was admitted for narcotic treatment on 01/11/2017, and discharged on 01/17/2017, but there was no documentation of an emergency contact for the patient.
Patient #3 was admitted for narcotic treatment on 01/10/2017, and discharged on 01/15/2017, but there was no documentation that the facility verified the patient's identity.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
All staff responsible will be trained by the Nurse Manager on the proper process for screening patients who will be entering the narcotic treatment program by 6/1/2017. This will include the following parameters for screening: verify the individual's identity, including name, address, date of birth, emergency contact and other identifying data. If a client has refused to provide an emergency contact this will be documented by the personnel responsible for conducting this part of the assessment.
To ensure this process is occurring correctly five random detox charts will be audited each month by the nurse manager. |