INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, New Way of Life 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 employee schedules and CPR certificates, the facility failed to ensure that at least one trained in CPR/First Aid was onsite at all times during the projects hours of operation during a review of schedules from July 14-August 10th 2019.
The following shifts lacked CPR/First Aid Coverage at all times:
July 15-18th 2019 from 7am until 9am
July 24-26th 2019 from 7am until 9am
July 29th-August 2nd from 7am until 9am
August 5th- 9th from 7am until 9am.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Firetree Corporate Compliance Officer and Corporate Clinical Director met with Facility Director on 8/7/19 to review audit finding to ensure his understanding of the staffing standard.
Facility Director will review his staff coverage with the Corporate Compliance Officer weekly beginning on 8/12/19 to ensure appropriate compliance; specifically addressing that First Aid/ CPR certified staff are on duty for each scheduled shift. |