INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 26-27, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Deerfield Dual Diagnosis 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 and a plan of correction is due on June 23, 2009.
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Plan of Correction
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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.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of the fire extinguisher upon staff employment, in one of one personnel records.
The findings include:
Three personnel records were reviewed on May 26-27, 2009. One personnel record required fire extinguisher training. The facility failed to document the completion of fire extinguisher training in personnel record # 3.
Employee # 3 was hired on March 11, 2009. Employee # 3 did not have documentation of the required fire extinguisher training.
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Plan of Correction
The Facility Director or the Clinical Supervisor will instruct the employee on the proper use of the fire extinguisher when she retruns from medical leave. Hereafter, all new employees will be trained in the proper use of a fire extinguishers as part of the initial new employee orientation process provided by the Facility Director or the Clinical Supervisor within 7 days of their start dat at the program. |
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.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies, in one of one personnel records.
The findings include:
Three personnel records were reviewed on May 26-27, 2009. One personnel record required the completion of emergency training. The facility failed to document the completion of emergency training in personnel record # 3.
Employee # 3 was hired on March 11, 2009. Employee # 3 did not have documentation of the required emergency training.
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Plan of Correction
The Facility Director or Clinical Supervisor will provide emergency training during the initial new employee orientation program. This will occur within 7 days of the new employe's starting date at the program.
The current employee will be instructed in emergency proceedures upon her return from medical leave. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of policy and procedures and personnel records, the facility failed to document a signed job description in one of one personnel record .
The findings include:
Three personnel records were reviewed on May 26-27, 2009. A signed job description was required in one personnel record. The facility did not document a signed job description in personnel record # 3.
Employee # 3 was hired on March 11, 2009.
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Plan of Correction
The Facility Director or Clinical Supervisor will have the employee sign her job description upon her return form medical leave.
The Facility Director will work with Human Resources to see that all new employees have signed there job description before they can begin working in the program. This will be addressed with the Human Resources Director within two days by the Program Director. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document physical examinations within five days in five of six client records.
The findings include:
Six records were reviewed on May 26-27, 2009. Physical examinations were required in six client records. The facility failed to complete physical examinations within five days as required by the project's policy in client records # 1, 2, 3, 4 and 6.
In client record #1 the individual was admitted on May 19, 2009. The physical examination was to be completed by May 24, 2009, but was not completed until May 25, 2009.
In client record #2 the individual was admitted on May 7, 2009. The physical examination was to be completed by May 12, 2009, but was not completed until May 25, 2009.
In client record #3 the individual was admitted on May 11, 2009. The physical examination was to be completed by May 16, 2009, but was not completed until May 25, 2009.
In client record #4 the individual was admitted on May 19, 2009. The physical examination was to be completed by May 24, 2009, but was not completed until May 25, 2009.
In client record #6 the individual was admitted on March 12, 2009. The physical examination was to be completed by March 17, 2009, but was not completed until March 20, 2009.
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Plan of Correction
In order to meet the requirement for history and physicals to be completed within 7 days of admission, the Counselors have been instructed to call a designated local Family Practionair to schedule appointments until a new CRNP is hired. Two candidates are being interviewed today. The Program Director and Clinical Supervisor will see that physicals are completed per regulation. |