INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 5-8, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, A.R.S. of Lancaster, LP, 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(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the facility's policy and procedure manual and the personnel policy manual, the facility failed to document a training procedure which included the time frames for the required components.
The findings include:
The agency training policy and procedure was reviewed during the annual licensing inspection on November 5, 2012. The personnel policy manual was reviewed on November 7, 2012. The procedures documented in the manuals did not document time frames for completion of the assessment of staff training needs component, the overall plan component, feedback, and the annual evaluation of the overall training plan.
This was discussed with the facility and project director and was not disputed.
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Plan of Correction
The project director has modified the personnel policy manual to reflect that all assessments of staff training needs component will be completed at the beginning of January, the overall plan component will be completed by the end of January and feedback, and the annual evaluation of the overall training plan will be completed at the end of December. This policy change will be presented for approval to the governing body at the next board meeting in December. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills were conducted during different times of the day.
The findings include:
The fire drill record was reviewed on November 5, 2012. Ten months of fire drills were reviewed. The facility's hours of operation are from 5:00 a.m. until 3:00 p.m. There were five drills documented between the hours of 11 a.m. and 12:45 p.m. and five drills documented between the hours of 6:34 a.m. until 8:33 a.m. The facility failed to document drills between the hours of 5:00 a.m. - 6:34 a.m. and from 12:45 p.m. until 3:00 p.m.
The facility director confirmed the findings.
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Plan of Correction
The health and safety officer will develop a yearly calendar at the beginning of each year detailing the day and time that each fire drill is scheduled. The Facility Director will review and approve this calendar to ensure that fire drills are scheduled on different days of the week and different times of the day to cover all hours of operations. |
709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
Based on a review of the facility's policy and procedures, the facility failed to identify the process for selecting a project director.
The findings included:
The facility policy and procedure manual and the corporate Bylaws were on November 5, 2012. No process for selection of a project director by the Board were specified in the documentation in the By Laws or in written agency policy.
The findings were discussed with the project director and facility director and were not disputed.
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Plan of Correction
The project director and governing body will modify the personnel policy manual and By Laws to dictate the selection process for a new project director. This will be presented at the next governing body meeting which is scheduled in December for approval. |