INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 6-7, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Peniel Drug and Alcohol Residential Treatment Facility 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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704.3(d) LICENSURE 24 Hour Coverage
704.3. General requirements for projects.
(d) Inpatient nonhospital facilities except for transitional living facilities and licensed facilities providing halfway house services shall have awake staff coverage 24 hours a day. Halfway houses shall have at least one staff person on the premises at all times.
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Observations
The facility failed to provide awake staff coverage 24 hours a day as determined during an interview with the Project/Facility Director during the licensing inspection on July 6-7, 2016. The 11 P.M. to 7 A.M. staff were not required to be awake during their shift. These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Since we have 5 staff who are already living on property, we have decided to develop a schedule from 11PM to 7AM which will be assigned to these staff members on a rotating basis. The 11PM to 7AM staff's responsibilities will be to remain awake and to monitor the clients throughout the night.
The Dormitory Supervisors will be responsible for implementing and monitoring the dorm staff scheduling which will include the 11PM to 7AM personnel schedules. |