INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on March 19 to 20, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, State College Medical 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:
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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 employee personnel and training records, the facility failed to document that each employee received fire extinguisher training upon hire. The findings included: The records of eight employees were reviewed on March 20, 2012. Each employee was required to have documentation that they received fire extinguisher training upon hire. Employee # 8 began employment on 6/15/2011. Fire extinguisher training was not documented as of the date of the review.The facility and project director were informed of the lack of documentation. The findings were not disputed as the administration had been unaware of the requirement.
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Plan of Correction
Employee #8 viewed Fire Extinguisher training video and reviewed Fire Safety material on 4/5/2012.
Each employee will complete this training upon new hire orientation, as well as annually. Employees will sign off on training form. This will be tracked on the New Hire Orientation checklist and annual training schedule, both maintained by facility director. |
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 employee personnel and training records, the facility failed to ensure that all personnel on all shifts are trained upon employment to perform assigned tasks during emergencies.The findings included: The records of eight employees were reviewed on March 20, 2012. Each employee was required to have documentation of training on assigned tasks during emergencies. Employee # 8 is contracted and began employment on 6/15/2011. Assigned tasks during emergencies training was not documented as of the date of the review.The facility and project director were informed of the lack of documentation. The findings were not disputed.
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Plan of Correction
On 4/5/2012, Employee #8 reviewed all Emergency Procedure Policies and signed verification of this.
Each employee will review Emergency Procedure Policies upon new hire orientation, and again annually. They will sign form to verify this training. This will be tracked by the Facility Director using New Hire Orientation checklist as well as annual training schedule. |
709.22(c)(2) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(2) Qualifications for membership.
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Observations
Based on a review of the facility's policy and procedures, the facility failed to identify qualifications for Board members in the facility policy or by laws. The findings included:During an administrative review on March 19, 2012, the facility's policy and procedures and the corporate by laws were reviewed. No qualifications for membership on the Board were specified in the documentation in the by laws or in written facility policy. This was reviewed with the Facility Director, Project Director and dispensing nurse. The issue was acknowledged as something to be addressed throughout the project.
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Plan of Correction
Director of Human Resources is consulting with the CEO to outline the qualifications in a document that will be maintained on site along with the Bylaws, board information/minutes and Governing Body documentation.
This will be in place by 5/1/2012. |
709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
Based on a review of the facility's policy and procedures, the facility failed to identify the process for selecting a project director. The findings included:During an administrative review on March 19, 2012, the facility's policy and procedures and the corporate bylaws were reviewed. No process for selection of a project director by the Board were specified in the documentation in the bylaws or in written facility policy. This matter was reviewed with the Facility Director, Project Director and dispensing nurse. The issue was acknowledged as something to be addressed throughout the project.
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Plan of Correction
Director of HR and CEO developed a policy for seleciting a Project Director.
It is now on file in the Policy and Procedure manual.
This policy will be maintained in the Policy and Procedure manual. This manual will be reviewed annually, and approved by the CEO and Project Director. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records, the facility failed to provide results of reference checks in four of ten personnel records. The findings included:Eight personnel records were reviewed on March 20, 2012. All personnel records required the documentation of reference results. The facility failed to document the results of reference checks in personnel record # 8.Employee # 8 began employment on 6/15/2011. Reference checks were not completed.The facility and project director were informed of the lack of documentation. The findings were not disputed.
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Plan of Correction
On 4/4/2012, Letters to request References were mailed to two individuals on the behalf of Employee #8. These letters will be returned to Facility Director by 4/27/2012. They will be maintained in personnel file of Employee #8.
All new employees will have two references upon their hire. These references will be maintained in personnel files. This will be tracked on New Hire Orientation checklist. This will be maintained by Facility Director. |