INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 3, 2007 through October 4, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Interim House West 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 26, 2007.
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Plan of Correction
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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.
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Observations
Based on a review of training records, the facility failed to ensure all staff were trained on the use of fire extinguishers in four of eight records were reviewed, #4, 6, 7 and 8. Documentation of training was not provided for employees #4 and 7. Documentation of training was not completed within the required time frame for employee's #6 and 8.
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Plan of Correction
IHW on-going fire extinguisher training is held on a quarterly basis; however due to staff oversight two staff members did not attend the training. Additionally, due to scheduling conflicts, two staff members did not recieve the training within the required timeframe
effective immediatly IHW will have fire extinguisher and fire safety training within the first week of employment and yearly thereafter.
Program Director will monitor and ensure compliance |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 training records, the facility failed to ensure that all staff were trained to perform assigned tasks during emergencies in four of eight records were reviewed, #4, 6, 7 and 8. Documentation of training was not provided for employees #4 and 7. Documentation of training was not completed within the required time frame for employee's #6 and 8.
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Plan of Correction
Effective immediately, IHW will hold fire extinguisher and fire safety training initially during staff orientation period, which occurs within the first 5 days of employment, and yearly thereafter.
the clinical director and program director will ensure compliance |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation in one of two records reviewed, #3 and 4.
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Plan of Correction
As part of the treatment process at IHW, client case consultations are held on a quarterly basis. Due to staff oversight, the case consultation for client #4 was completed, however it was not filed in the client's chart.
Effective immediately, the clinical director will provide a brief inservice to the clinical team to ensure case consultation information is documented and filed in a timely manner.
Clinical director will monitor compliance.
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