This report is a result of an on-site follow-up inspection to the on-site licensure inspection conducted on July 27, 2010 and July 28, 2010 by staff from the Division of Drug and Alcohol Program Licensure.
The follow-up inspection was conducted on January 28, 2011 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site follow-up 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.
The following deficiencies were identified during this inspection and a plan of correction is due on March 1, 2011.
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Plan of Correction
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Observations
Based on observation during the physical plant inspection conducted on January 28, 2011 and a conversation with the quality assurance representative, the facility failed to ensure that there were no heaters that were not permanently mounted or installed located within the facility.
The findings include:
A counselor's office included a portable space heater that was not permanently mounted or installed.
The quality assurance representative and the counselor confirmed that the office had a portable space heater.
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Plan of Correction
Immediate Plan of Correction:
(1) The portable space heater in the administrative office in the Outpatient Addiction program was immediately removed from the department, 1/28/11;
(2) Maintenance inspected the remainder of the department to ensure there were no other portable space heaters, 1/28/11; and
(3) The manager of the department reviewed the regulation, 705.26, at a staff meeting, to assure staff knows portable space heaters are not permitted in the facility.
Performance Improvement to Sustain Compliance:
Environment of Care rounding in the department is conducted on a regular basis. Rounds will include ensuring no portable space heaters are in use. Oversight for rounds will be conducted by the PPMC Environment of Care Surveillance rounding team.
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