INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the December 17-19, 2008 licensure renewal inspection. The follow-up inspection was conducted on July 30, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Narcotic Addict Rehabilitation Program of Thomas Jefferson University 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 September 2, 2009.
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Plan of Correction
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 document that all personnel were trained to perform assigned tasks during emergencies that took place at the 21st Street location.
Findings:
Three personnel files were reviewed during a follow up visit to the facility on 7/30/09. Site-specific training to perform assigned tasks during emergencies was required in 3 personnel records. The facility did not document that there was training to perform site-specific assigned tasks during emergencies in personnel records #1, 2 & 3.
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Plan of Correction
Site specific training with respect to assignment of tasks in case of a local emergency will be formally documented for all new hires and maintained in their personnel record. It will be the responsibility of the new employee's immediate supervisor to assure that this is accomplished upon reporting for duty. |