INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 4 through 5, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Nuestra Clinica Rehabilitacion 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 February 29, 2008.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a February 4 through 5, 2008 review of training records, the facility failed to document HIV/AIDS and TB/STD training in two of six records reviewed, #1 and 6.
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Plan of Correction
Staff HIV/AIDS and TB/STD training took place on March 5, 2008. Another staff training will be held on May 10, 2008. By the May training all new and current staff will have received the HIV/AIDS and TB/STD training. The Project Director and Clinical Supervisor will document and ensure that the staff receive the training. |
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.
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Observations
Based on a February 4 through 5, 2008 review of staff schedules and training records, the facility failed to document a sufficient number of persons CPR certified during the project's hours of operation. There was not sufficient coverage on the third shift on January 15, 17, 22, 24, 29, 31, February 5 and 7, 2008. The first shift on the weekends had no coverage from 8:00 AM to 1:00 PM on February 2, 3, 9 and 10, 2008.
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Plan of Correction
All new and current staff in need of CPR training will receive the training on April 1, 2008. The Project Director and Clinical Supervisor will document and ensure that the staff are trained. |
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 February 4 and 5, 2008 review of employee records, the facility failed to document fire extinguisher training within the required time frame in two of six records reviewed, #2 and 4.
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Plan of Correction
The staff will receive the fire extinguisher training within 7 days of hire. The Project Director and Clinical Supervisor will document that the training has been provided and that the staff has participated. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a February 4 and 5, 2008 inspection of policies and administrative records, the facility failed to document monthly inspections of drug storage areas. The facility's policy stated that drug storage areas would be inspected monthly. Inspections were missing for four of five months reviewed, September 2007, November 2007, December 2007 and January 2008.
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Plan of Correction
The facility will inspect and record the drug storage area contents on a monthly basis. The Project Director and Clinical Supervisor will ensure that proper monthly records of the drug storage area are maintained. |