INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 1, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Penn Presbyterian Medical Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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.
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Observations
Based on the review of the facility's fire drill record, the facility failed to document problems encountered on the fire drill record and failed to ensure that the drill took a reasonable time for evacuation during the fire drills.
The findings include:
The fire drill record was reviewed on July 31, 2012. The fire drill record failed to include on the fire drill log any problems encountered during the fire drills. The following months were reviewed: August 2012, September 2012, October 2012, November 2012, December 2012, January 2012, February 2012, March 2012, April 2012, May 2012, June 2012 and July 2012. Also, the facility did not document in a reasonable time for the evacuation of clients and staff during the fire drills. The following dates and times documented:
August 31, 2012 20 mins.
September 21, 2011 20 mins.
October 21, 2011 15 mins.
November 22, 2011 15 mins.
December 16, 2011 20 mins.
January 17, 2012 15 mins.
February 17, 2012 20 mins.
March 9, 2012 20 mins.
April 30, 2012 15 mins.
May 22, 2012 20 mins.
June 22, 2012 20 mins.
July 23, 2012 20 mins.
An interview with the clinical supervisor on August 1, 2012 confirmed the findings.
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Plan of Correction
1. The Outpatient Detoxification Unit received an inservice from the PPMC Safety Officer immediately following the survey regarding the ongoing official fire drill critiques conducted per PPMC Fire Safety policy. These drills do include a more timely evacuation period, as well as a critique of the overall drills which allows for a reporting of any problems, Completed on August 1, 2012. The Outpatient Detoxification Unit will receive copies of these reports to include with the unit's own internal fire drill critiques effective immediately.
2. The unit will continue to conduct its own fire drills using a new modified log to record the performance of each drill per standard 705.28 (d) (4). The Outpatient Fire Drill Log was revised to include the actual time the drill was initiated and time the drill cleared to indicate the actual evacuation time. The log was also modified to include the problems encountered. The unit logs/critiques will also be shared with the PPMC Safety Officer to ensure the staff are conducting drills per policy and critiquing the unit's performance accurately. The form was revised for use as of 8/13/2012.
3. The Nurse Manager of Addiction Services or designee, and the PPMC Safety Officer will collaborate to ensure all standards are met and documented per policy and standard. The findings and action plan will be submitted by the Safety Officer to the next scheduled Environment of Care (EOC) Committee meeting with follow-up to PPMC Board of Trustees.
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills are conduct on different times of the day.
The findings include:
The fire drill record was reviewed on July 31, 2012. There was eleven fire drills conducted on the morning shift, and one on the afternoon shift. The following months were reviewed August 2011, September 2011, October 2011, November 2011, December 2011, January 2012, February 2012, March 2012, April 2012, May 2012, June 2012 and July 2012. The facility's hours are Monday through Friday 8:30 am to 4:30 pm.
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Plan of Correction
1.The Nurse Manager of Addiction Services collaborated with the PPMC Safety Officer to come up with a system to conduct drills on different days of the week, as well as different times of the day during the programs operating hours which are from 8:30am to 4:30pm, Monday through Friday. The new schedule will be effective starting August 13, 2012.
2.Beginning August 2012, fire drills will be conducted at different times of the days and this will be ongoing.
3.The findings and action plan will be submitted by the Safety Officer to the next scheduled Environment of Care (EOC) meeting with follow-up to PPMC Board of Trustees.
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711.94 (g) LICENSURE Medical Assistance Provider Agreement
711.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records and a discussion with the Facility Director, the facility failed to have a current, signed provider agreement with the Department of Public Welfare.
The findings include:
The policy and procedure manual was reviewed on July 30, 2012. The facility failed to provided a copy of the signed provider agreement with the Department of Public Welfare, instead provided the licensing inspector a copy of their signed provider agreement with their local insurance company. An interview with the facility director on August 1, 2012 confirmed the information that was provided to the licensing inspector.
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Plan of Correction
A copy of the PPMC Medical Assistance Program Provider Agreement for Drug and Alcohol Services was obtained from the Department of Public Welfare. A copy of the agreement will be maintained in the University of Pennsylvania Health System (UPHS) contract management system, PennTract. The unit manager will also retain a copy in the the Drug and Alcohol policy and procedure manual for any further requests/reviews. |