INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 16, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Catholic Charities Diocese of Harrisburg, PA, 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:
|
Plan of Correction
|
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of personnel records it was determined that the facility failed to ensure that all staff were instructed in the use of fire extinguishers upon employment.
The findings include:
A review of 6 personnel records on July 16, 2015 revealed that two employees were not instructed in the use of the fire extinguisher upon their employment.
Employee #5 was hired on 3/28/2015. The facility failed to provide documentation of this training at the time of inspection.
Employee #6 was hired on 6/20/2015. The facility failed to provide documentation of this training at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As part of the Individual Training Plan which occurs within the first week of hire, fire safety and emergency training will be addressed and dated on this written plan. It will then be filed within the first week of training as documentation in personnel files that fire safety and emergency training occurred. The Program Director will be accountable for this plan being signed, personnel trained, and documentation filed. This new addition to the plan will start immediately, being initiated with the next new hire. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of personnel records it was determined that the facility failed to ensure that all personnel were trained to perform assigned tasks during emergencies.
The findings include:
A review of six personnel records on July 16, 2015 revealed that two employees did not receive training in order to perform assigned tasks during emergencies.
Employee #5 was hired on 3/28/2015. The facility failed to provide documentation of this training at the time of inspection.
Employee #6 was hired on 6/20/2015. The facility failed to provide documentation of this training at the time of inspection.
These findings were reviewed with facility staff during the licensing process
|
Plan of Correction
As part of the Individual Training Plan which occurs within the first week of hire, fire safety and emergency training will be addressed and dated on this written plan. It will then be filed within the first week of training as documentation in personnel files that fire safety and emergency training occurred. The Program Director will be accountable for this plan being signed, personnel trained, and documentation filed. This new addition to the plan will start immediately, being initiated with the next new hire. |