INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on June 19-20, 2019. Based on the findings of the on-site inspection, Endless Mountains Extended Care, LLC was found to not be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
The following deficiencies were identified during this inspection:
|
Plan of Correction
|
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.
|
Observations
During a review of staff files on June 19-20, 2019, the facility failed to instruct all staff in the use of the fire extinguishers upon staff employment.
Staff #4 who was hired as a counselor on May 7, 2019 had not yet been trained in the use of the fire extinguisher.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
In accordance with 705.10, The Facility Director will ensure that each new employee is trained in the use of fire extinguishers within 3 days of their date of hire.
As of June 24, Staff #4 was trained in the use of fire extinguisher. In addition, the Facility Director revised the wording from "fire safety apparatuses" to "fire extinguisher" in the P&P and employee manual to specifically designate that the staff was trained on use of fire extinguishers. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
During an onsite review of fire drill reports, the facility failed to document in the fire drills the exit route used to exit the building and problems encountered.
The fire drill dated for April 5, 2019 did not document the time it took to evacuate the building.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
In accordance with 705.10, the Facility Director will ensure that each fire drill report will specify which exit route was used as well as a listing of problems encountered during the drill. Going forward, the Facility Director will also always ensure that the time it took to evacuate the building is always listed in the "Duration" section of the report. The timer will be used to ensure the exact time is accurately documented.
The Facility Director will complete each fire drill report (or monitor each report immediately with the staff assigned to oversee the fire drill) to maintain compliance for each monthly fire drill. |