INITIAL COMMENTS
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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. Pottstown 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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704.11(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.
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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 was onsite during the project's hours of operation. The findings include:: Based on a review of staff schedules and staff CPR/first aid certification cards, the facility failed to have sufficient staff trained in these skills on duty. This facility had only one staff for all coverage. An interview with the program coordinator confirmed the facility failed to have sufficient amount of coverage needed.
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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.
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Observations
Based on a review of the fire drill record log, the facility failed to document two monthly fire drills. The findings include: The fire drill record log was reviewed on December 7, 2011. The log was reviewed from December 2010 to November 2011. Two of those twelve months did not document that a fire drill was conducted. July 2011 and August 2011 were the two months that the facility did not document fire drills. This was confirmed with the program coordinator on December 13, 2011.
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Plan of Correction
This facility did not have clients or staff at the program during the summer months. During the summer months if the outpatient program is operating in Pottstown, fire drills will be conducted and recorded. The project director and clinical supervisor will train summer program staff by 5/15/12 how to implement and document fire drills. |