INITIAL COMMENTS
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This report is a result of an un-announced site inspection conducted on December 28, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Rehab Management, Inc. 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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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.
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Observations
Based on a review of personnel records, the facility failed to ensure that each staff person received the required training in the use of a fire extinguisher.
The findings included:
Two personnel records requiring documentation of fire extinguisher training were reviewed on December 28, 2011. One of two records reviewed, record #2, lacked documentation that the staff person had received fire extinguisher training.
Staff person #2 started an unpaid internship started on 7/8/2011. According to the facility's policies, volunteers will be hired using the same process as a new employee. The personnel record was reviewed and no documentation was recorded to indicate that the intern had ever received fire extinguisher training.
The Facility Director was interviewed and confirmed this finding.
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Plan of Correction
The site director of Daylesford will meet with the intern & staff member on 1/13/2012 to perform fire safety inservice. This will be documented by the site director and placed in the personel files.
The site director of Daylesford will ensure that any new hires or interns be trained according to company policy and documentation is placed in their personel file within stated time frames. |
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.
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Observations
Based on a review of employee personnel records, the facility failed to ensure that each employee received the required training to perform assigned tasks during emergencies.
The findings included:
Two personnel records were reviewed on December 28, 2011. Each was required to have documented training for emergencies. One of two records failed to document that the employee had received training on what to do in the event of an emergency.
Staff person #2 was hired as an unpaid intern on or about 7/8/2011. According to the facility's policies, volunteers will be hired using the same process as a new employee. The personnel record was reviewed and no documentation was recorded to indicate that the intern had ever received training for assigned tasks during emergencies.
The Facility Director was interviewed and confirmed this finding.
Two personnel records requiring documentation of fire extinguisher training were reviewed on December 28, 2011. One of two records reviewed, record #2, lacked documentation that the staff person had received fire extinguisher training.
Staff person #2 started an unpaid internship started on 7/8/2011. According to the facility's policies, volunteers will be hired using the same process as a new employee. The personnel record was reviewed and no documentation was recorded to indicate that the intern had ever received fire extinguisher training.
The Facility Director was interviewed and confirmed this finding.
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Plan of Correction
The site director of Daylesford will meet with the intern & staff member on 1/13/2012 to perform fire & emergency evacuation protocol. This will be documented by the site director and placed in the personel files.
The site director of Daylesford will ensure that any new hires or interns be trained according to company policy and documentation is placed in their personel file within stated time frames. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on the review of personnel records, the facility failed to document reference checks in one of two records reviewed.
The findings include:
Two personnel records were reviewed. According to the facility's policy and procedures, "Volunteers will be hired using the same process as a new employee. Any new volunteer will be expected to abide by the same policies as staff." Staff person # 2 was engaged as an unpaid intern on 7/8/11. . The facility failed to document employment reference checks, FBI Clearance and Child Abuse Clearances for patient record # 2.
This finding was confirmed by the Facility Director.
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Plan of Correction
The site director of Daylesford will ensure that Rehab After Work Human Resource Department completes required employment reference checks, FBI Clearance and Child Abuse Clearances for the intern involved. The Human Resources Director will monitor progress every two weeks until documentation is verified and recieved. The HR department will place proper proof in the intern's personnel file at Daylesford.
Site Director will provide monitoring of this process on any new hires at Daylesford in the future. Audits will be completed monthly to ensure compliance. |
709.26(d)(3) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(3) The verification of training experience and professional licensure or registration, where applicable.
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Observations
Based on the review of personnel records, the facility failed to document verification of the employee's training experience and professional licensure or registration.
The findings include:
Two personnel records were reviewed. According to the facility's policy and procedures, "Volunteers will be hired using the same process as a new employee. Any new volunteer will be expected to abide by the same policies as staff." Employee # 2 was engaged as an unpaid intern on 7/8/11. The facility failed to document verification of staff person #2's degree and credentials.
This finding was confirmed by the Facility Director.
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Plan of Correction
The site director of Daylesford will ensure that Rehab After Work Human Resource Department completes required verification of intern's degree/credentialsfor. The Human Resources Director will monitor progress every two weeks until documentation is verified and recieved. The HR department will place proper proof in the intern's personnel file at Daylesford.
Site Director will ensure monitoring of this process on any new hires/interns at Daylesford in the future. Audits will be completed monthly to ensure compliance |