INITIAL COMMENTS
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This report is a result of an on-site inspection to this newly licensed facility following the admittance of its first client. The inspection was conducted on July 12, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings on this on-site inspection, Pa Associates, LlcD/b/a Mt. Pocono Medical 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 and a plan of correction is due on August 8, 2010.
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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 document the instruction of staff in the use of the fire extinguisher upon staff employment, in two of five personnel records.
The findings include:
Five personnel records were reviewed on July 12, 2010; all were required to provide documentation of instruction to use the fire extinguisher upon employment. Personnel record # 3 did contain documentation that instruction in the use of a fire extinguisher had taken place but there was no date on the documentation to verify when the training had occurred upon employment. Personnel record # 5 contained documentation that revealed that the staff was hired on 3/29/10 but not trained until 4/22/10.
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Plan of Correction
705.28(C)(4)
All personnel files have been reviewed and updated for compliance using our in house form that documents all clinic trainings with the dates and signatures of completion.
Facility Director will ensure compliance in the use of the fire extingusher. |