INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 9, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mercy House of Meadville 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 April 11, 2011.
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Plan of Correction
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to document the instruction of staff in the use of the fire extinguisher upon staff employment, in two of two personnel records.The findings include:Six personnel records were reviewed on March 9, 2011. Two employees required fire extinguisher training upon employment. Per regulation, the nonresidential facility shall instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel records # 4 and 5.Employee # 4 was hired on January 6, 2011. There was no documentation that employee # 4 completed fire extinguisher training. Fire extinguisher training was not completed upon staff employment, as required.Employee # 5 was hired on July 7, 2010. There was no documentation that employee # 5 completed fire extinguisher training. Fire extinguisher training was not completed upon staff employment, as required.An interview with the project/facility director on March 9, 2011 confirmed that employees # 4 and 5 had not completed the fire extinguisher training as required.
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Plan of Correction
The 2 staff people were trained on 3/17/11 on the use of fire extinguishers by the head custodian. This was documented in personell records. In the future it will be the facility director's responsibility to make fire instruction safety a part of the employee signing on process. |
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 and an interview with the facility director, the facility failed to document that all personnel on all shifts are trained to perform assigned tasks during emergencies, in two of two personnel records.The findings include:Six personnel records were reviewed on March 9, 2011. Two employees required emergency training. Per regulation, the nonresidential facility shall ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies. Verification of this training was not documented in personnel records # 4 and 5.Employee # 4 was hired on January 6, 2011. There was no documentation that employee # 4 completed emergency training. Emergency training was not completed as required.Employee # 5 was hired on July 7, 2010. There was no documentation that employee # 5 completed emergency training. Emergency training was not completed as required.An interview with the project/facility director on March 9, 2011 confirmed that employees # 4 and 5 had not completed the fire emergency training as required.
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Plan of Correction
Employees 4 and five were trained on emergency procedures for fires or other natural disasters by facility director and it was documented. Facility director will be responsible for perforning this training in the future as part of the amployee signing on process, This training will be documented in future personell records. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative policies and procedures, the 2009 audit and an interview with the project/facility director, project failed to complete the 2009 audit by the end of the project's fiscal year, as required by regulation.The findings include:A review of administrative policies and procedures and the 2009 audit was conducted on March 9, 2011. Per regulation, the project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services. The project's fiscal year is from January through December. The project's audit for January 1, 2009 through December 31, 2009 was due to be completed no later than June 30, 2010. The project failed to document the completion of an annual audit for the 2009 fiscal year. An interview with the project/ facility director of March 9, 2011 confirmed that a 2009 audit had not been completed.
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Plan of Correction
We were not licensed until July 2009 and therefore had not completed a fiscal year. 2010 would have marked our first full fiscal year.-requesting this be removed |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on the review of client records and an interview with the project/facility director, the facility failed to document follow-up information in one of one client record. The findings include:Five client records were reviewed on March 9, 2011. One client record required follow-up information. Per agency policy, follow-up for non-referred clients is to occur at one month. The facility failed to document follow-up per agency policy in client record # 5. Client # 5 was admitted on October 11, 2010 and discharged on January 3, 2011. Follow-up was due on February 3, 2011. There was no documentation that follow-up had been completed as of March 9, 2011. An interview with the project/facility director on March 9, 2011, confirmed that there was no follow up documentation in the above client record.
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Plan of Correction
Clinical supervisor will be responsible for managing follow-up contact. A list will be developed after discharge with time frames for future contact. Office manger or clinician will perform and document follow-up at the one month time-frame. |