INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 20-21, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD Womanspace was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records and CPR/First Aid certification cards, the facility failed to ensure that a sufficient number of staff persons were trained in First Aid.The findings include:Six personnel records and all employee CPR/First Aid certification cards were reviewed on June 20, 2013. There was only one staff person who didn't show documentation of first aid training and they work several nights alone, #6. The facility is open 24 hours Sunday through Saturday. A two month work schedule was reviewed and showed several days where employee #6 worked alone with no first aid coverage.5/2 - 6 pm to 12 am5/3 - 4 pm to 12 am5/9 - 6 pm to 12 am5/10 - 4 pm to 12 am5/11 - 12 am to 8 am5/12 - 8 am to 4 pm5/13 - 4 pm to 12 am5/16 - 6 pm to 12 am5/17 - 4 pm - 12 am5/18 - 12 am to 8 am5/19 - 8 am to 4 pm5/20 - 4 pm to 12 am5/23 - 6 pm to 12 am5/24 - 4 pm to 12 am5/25 - 12 am to 8 am5/ 26 - 4 pm to 12 am5/27 - 12 am to 8 am5/30 - 6 pm to 12 am6/8 - 12 am to 8 am6/9 - 8 am to 4 pm6/17 - 12 am to 8 amAn interview with the facility director on June 21, 2013, confirmed the findings.
|
Plan of Correction
All active employees must present proof of First Aid certification prior to working their next scheduled shift.
Program Director will ensure that proof of First Aid certification be presented prior to next scheduled shift.
Office Manager will collect proof of First Aid certification from all new employees upon hire during the New Hire paperwork completion session, which occurs prior to any training and/or working shifts.
Program Director will review all new hire personnel files to ensure that proof of First Aid has been obtained prior to working scheduled shifts.
New employees will not be approved to work individual shifts prior to presenting proof of First Aid Certification. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on a review of the fire drill record, the facility failed to conduct a fire drill during sleeping hours at least once every six months.The findings include:The fire drill record was reviewed on June 20, 2013. The fire drill logs were reviewed from the last survey, June 2012 to May 2013. During that time frame, the facility documented two fire drill during sleeping hours, 9/22/12 and 5/31/13. An interview with the facility director on June 20, 2013 confirmed the findings.
|
Plan of Correction
Program Director will review fire drill expectations during All Staff Meeting on 7/10/13 to ensure that all current employees are aware of current expectations.
Fire Drill expectations will be emphasized during new hire training and orientation by appropriately designated staff trainee.
Office Manager will edit current fire drill schedule to ensure that an overnight fire drill is scheduled at least once every six months.
Program Director will review fire drill log on a monthly basis to ensure that one overnight fire drill occurs within the regulation 6 month period.
Program Director will review edited fire drill schedule as well as all updated fire drill schedules to ensure that an overnight fire drill is scheduled once every six months. |