INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 23, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on June 25, 2007.
|
Plan of Correction
|
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
The facility failed to document fire extinguisher training in three of five personnel files reviewed. File review numbers 1, 2 and 3
|
Plan of Correction
Three employees did not have documentation of fire extinguisher instruction completed & placed in their personel files within 7 days of hire date. The site director of Lansdale will orient all three employees on "How to use fire extinguishers at the site" & have each employee sign off that this instruction is completed by 6/22/07. Documentation will be placed in their personel files. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
The facility failed to document emergency fire safety training in three of five personnel files reviewed. File numbers 1, 2 and 3.
|
Plan of Correction
Three employee files at the Lansdale office did not have proof of fire safety trainings. The site director of Lansdale will meet with these employees and review all fire saftey protocols listed in our site manual. The employees will sogn off that this training has been completed & documentation of this in-srevice will be placed in their employee files by 6/30/2007 |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
|
Observations
The project director failed to establish project goals and objectives with time frames and available resources. A review of governing body information, to include board meeting minutes and quarterly reports, failed to include the necessary documentation.
|
Plan of Correction
The president/project director, stated project goals and included these in the governing body minutes, but without specific goals and time frames included in the report. The project director with help for our administrative manager, will write down the specific objectives with quarterly time frames reported/included by 6/21/2007. These will be documented & included in the 2007 Governing Body report after approval from the Governing Body by 6/30/2007. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
|
Observations
A review of the organization's treatment management plan and letters of agreement failed to document an agreement for 24 - hour emergency psychiatric coverage.
|
Plan of Correction
A current 24 hour medical emergency referral agreement letter was not located at the Lansdale site the day of the inspection. This letter was located later at the Paoli site. The site director will ensure that a current, updated letter of agreement will be forwarded to the Lansdale office & placed in the referral agreement log at the Lansdale site by 6/30/2007 |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
|
Observations
The project failed to provide documentation of the projects efforts toward informing employees number 1, 2 and 3 of employee rights in three of four personnel files reviewed.
|
Plan of Correction
Employee rights are included during the orientation period and placed in personel files. Three files at Lansdale did not include this documentation. The site director of Lansdale will meet with the three employees affected; review employee rights stated in our manual; and have each employee sign off that this was completed. This documentation will be placed in their personel files by 6/22/2007. |