INITIAL COMMENTS
|
This report is a result of an initial on-site licensure inspection conducted on August 21, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Diakon Family Life Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
Since this was the initial inspection conducted, not all regulations were reviewed. During future inspections, all regulations will be reviewed for compliance.
|
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, the facility failed to provide a sufficient number of staff persons with current CPR certification to cover all hours of operation.
The findings include:
The personnel records were reviewed on August 21, 2012. Three of the five employees were required to have current CPR certifications, employees # 3, 4 and 5. Two of the three employees did not have current CPR certification.
Employee #4 - CPR certification expired on June 12, 2012. As of the time of the initial site inspection, there was no documentation current CPR certification for employee # 4.
Employee #5 - CPR certification expired on June 12, 2012. As of the time of the initial site inspection, there was no documentation of current CPR certification for employee # 5.
An interview with the facility director and clinical director on August 21, 2012 confirmed the findings.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
Based on the physical plant inspection, the facility failed to provide hot water.
The findings include:
The physical plant inspection took place on August 21, 2012. The hot water pressure was tested. The temperature did not register above 98 degrees Fahrenheit.
The staff confirmed that the hot water was not operational.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
|
Observations
Based on a physical plant inspection, the facility failed to ventilate the bathroom by an exhaust fan or window.
The findings include:
The physical plant inspection took place on August 21, 2012. The facility did not have an exhaust fan or window in the bathroom.
An interview with the facility director and clinical director on August 21, 2012 confirmed the findings.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.24(b) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
|
Observations
Based on a review of the facility's policy and procedure manual, the facility failed to provide documentation of letters of agreements or understanding with primary referral sources.
The findings include:
The policy and procedure manual was reviewed on August 21, 2012. The facility did not document letters of agreement or understanding with primary referral sources.
An interview with the facility director and clinical director on August 21, 2012 confirmed the findings.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
|
Observations
Based on the physical plant inspection, the facility failed to post the hours of project operations in an area visible to the general public.
The findings include:
The physical plant inspection was conducted on August 21, 2012. The hours of operation was not posted.
An interview with the facility director and clinical director on August 21, 2012 confirmed the findings.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
|
Observations
During the tour of the physical plant, the facility failed to have an emergency telephone number posted.
The findings include:
The physical plant tour took place on August 21, 2012. During the tour it was observed that the emergency telephone number was not posted.
An interview with the facility director and clinical director on August 21, 2012 confirmed the findings.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |