INITIAL COMMENTS
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This report is a result of an initial on-site licensing inspection conducted on January 28, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the initial inspection, Hope Springs Behavioral Health Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
As this was the initial inspection conducted, not all regulations were reviewed. During future inspections, all regulations will be reviewed for compliance.
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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 the facility's CPR certifications and first aid trainings, the facility failed to provide first aid training to a sufficient number of staff persons.
The findings include:
The CPR certifications and first aid trainings were reviewed on January 28, 2015. At least one person is to be trained in these skills. The facility failed to document first aid training for their employees, as of the date of the licensing inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on an observation during the physical plant inspection, the facility failed to maintain a minimum of two exits that are separated by a minimum distance of 15 feet on every floor.
The findings include:
The physical plat inspection took place on January 28, 2015. The facility failed to maintain a minimum of two exits on every floor. The second floor only had one means of egress.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.84(b) LICENSURE Project management services
709.84. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display the hours of operation to the general public.
The findings include:
A physical plant inspection was conducted on January 28, 2015.
The facility failed to display the project's hours of operation to the general public.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |