INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 11, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Merakey Montgomery County 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:
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Plan of Correction
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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.
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Observations
Based on a review of personnel records and the Staffing Requirement Facility Summary Report, the facility failed to ensure a sufficient number of staff persons with CPR certification and first aid training were onsite during the project's hours of operation.
The facility ' s hours of operation are Monday through Thursday from 8:30am-7:00pm and Friday from 8:30am-5:00pm. The facility provided CPR certification and first aid training documentation for employee #3; however, this individual is only onsite for 3.5 hours per week. Additionally, the CPR certification and first aid training was provided for employee #4; however, this employee is only onsite for 8 hours per month.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All current staff training files have been reviewed as of October 11, 2024, and training will continually be discussed during monthly supervisions. For the upcoming 2024-2025 licensing year, employee #5, our full-time (37.5 hours) Medical Office Assistant, will complete the CPR and first aid training on November 19th, 2024. DDAP Training requirements will be reviewed during clinical/administrative supervisions, tracked using the training plan, and documented in monthly supervisory notes to ensure compliance with DDAP training regulations.
The Project Director will complete a training plan with all project staff at the time of hire and ensure full and part time members are CPR/First Aid trained and certified to meet DDAP regulatory requirements as outlined in section 704.11 c (2) of the Pennsylvania Code.
Beginning November 4th, 2024, additional full-time staff will be added to the drug and alcohol project to ensure at least one staff trained in CPR and First Aid is onsite during the project's hours of operation.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's November 2023 through September 2024 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
There were no fire drills conducted during the months of December 2023, January 2024 through April 2024, and June 2024.
This finding was reviewed with the facility during the licensing process.
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Plan of Correction
The Project Director or designee will ensure fire drills are conducted every month by sending a calendar reminder to the Operation Manager by the 5th of every month to complete a fire drill and fire drill logs. Fire drill safety and compliance will be reviewed during monthly PQI meetings with the Director of Operations, Executive Leadership and Clinical Operations.
Monthly PQI meetings are scheduled for the second Tuesday of every month. Fire drill safety and when drills are scheduled will be monitored monthly
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