INITIAL COMMENTS
|
This report is a result of an on-site licensure inspection conducted on September 20, 2010 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site inspection, Center For Addictive Disease - Main Line Affiliates 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 October 23, 2010.
|
Plan of Correction
|
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.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report and an interview with the Project Director, the facility failed to provide a sufficient number of staff persons trained in CPR and First Aid FA during the project's hours of operation.
The findings include:
Facility Hours of operation are:
Monday through Thursday 8:30 AM- 9:00 PM
Friday 9:00 AM through 5:00 PM
On September 20, 2010 the facility presented the Staffing Requirements Facility Summary Report along with copies of the staff persons current CPR and First Aid cards to the Licensing Specialist. The documentation presented for CPR certification and First Aid certification were for three employees as follows:
Employee # 2 is the Facility Director for two facilities.
She works at the Drexel Hill site on Monday from 9 AM - 6 PM and Thursday 9 AM - 6 PM.
Employee # 5 is the Office Manager for two facilities.
She only works at the Drexel Hill site on Thursday from 8:30 AM - 6:00 PM
Employee # 6 is the Secretary and works from 9:30 AM - 8 PM.
The Project Director was asked about two additional counselors.
It was determined that neither of these counselors had current CPR or First Aid certifications.
There was no one certified in CPR or First Aid on site from 8 PM - 9 PM Monday through Thursday.
The Project Director confirmed that there was insufficient CPR and First Aid coverage during the project's hours of operation.
|
Plan of Correction
Drug and Alcohol Counselor in building until 9pm will enroll and complete CPR certification course. |