INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago Snyder 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 May 14, 2011.
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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 personnel records and an interview with the facility director, the facility failed to document the instruction of staff in the use of the fire extinguisher upon staff employment, in two of five personnel records.
The findings include:
Five personnel records were reviewed on March 25, 2011. Two employees required fire extinguisher training upon employment. Per regulation, the nonresidential facility shall instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel records #4 and #5.
Employee # 4 was hired on March 2, 2011. There was no documentation in the personnel record that employee #4 had completed fire extinguisher training.
Employee #5 was hired on January 31, 2011. There was no documentation in the personnel record that employee #5 had completed fire extinguisher training.
This was discussed with the facility director on March 25, 2011 and the facility director confirmed that fire extinguisher training had not been completed.
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Plan of Correction
The corporate compliance officer for Firetree, Ltd. will retrain the facility management staff of Conewago Snyder on the appropriate completion and documentation of staff fire extinguisher training on 4/8/11 to ensure their understanding.
The two employees whose training was found to not be properly documented during the on-site licensing inspection conducted on 3/25/11 were retrained on 4/8/11 by the facility director and the training documented with a training certificate placed in the respective personnel files.
The facility director will ensure that all future staff hired receives their fire safety/fire extinguisher training within the appropriate time frame and that the trainings are properly documented with a training certificate in their personnel files.
The facility director will ensure ongoing compliance by monitoring training completion and documentation during regular personnel file audits on a monthly basis by 5/31/11. |
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 personnel records and an interview with the facility director, the facility failed to document that all personnel on all shifts are trained to perform assigned tasks during emergencies, in of two of five personnel records.
The findings include:
Five personnel records were reviewed on March 25, 2011. Two employees required training to perform assigned tasks during emergencies. Per regulation, the nonresidential facility shall ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies. This instruction shall be documented by the facility. The facility failed to document the completion of this training in personnel records #4 and #5.
Employee # 4 was hired on March 2, 2011. There was no documentation in the personnel record that employee #4 had completed emergency training.
Employee #5 was hired on January 31, 2011. There was no documentation in the personnel record that employee #5 had completed emergency training.
This was discussed with the facility director on March 25, 2011 and the facility director confirmed that fire extinguisher training had not been completed.
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Plan of Correction
The corporate compliance officer for Firetree, Ltd. will retrain the facility management staff of Conewago Snyder on the appropriate completion and documentation of staff fire safety procedures training on 4/8/11 to ensure their understanding. The two employees whose training was found to not be properly documented during the on-site licensing inspection conducted on 3/25/11 were retrained on 4/8/11 by the facility director and the training documented with a training certificate placed in the respective personnel files. The facility director will ensure that all future staff hired receives their fire safety/fire extinguisher training within the appropriate time frame and that the trainings are properly documented with a training certificate in their personnel files. The facility director will ensure ongoing compliance by monitoring training completion and documentation during regular personnel file audits on a monthly basis by 5/31/11. |