INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on July 31,2012 and August 1, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Conewago Snyder 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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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to ensure all staff was instructed upon hire in the use the fire extinguishers.
The findings include:
Five staff files were reviewed on July 31, 2012. Two of five staff received fire extinguisher training late.
Staff # 4 was hired on November 30, 2011. Fire extinguisher training was completed on February 28, 2012.
Staff # 5 was hired on December 5, 2011. Fire extinguisher training was completed on December 31, 2011.
This finding was confirmed by the facility Director on August 1, 2012.
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Plan of Correction
Corporate compliance officer retrained the facility director on 8/9/12 on the appropriate completion and documentation of employee fire extinguisher and emergency training. Facility director will ensure that all future staff hired will receive the training within the initial week of hire and will document accordingly in the personnel file. The corporate compliance officer will ensure ongoing compliance through monthly on-site personnel file audits beginning on 8/31/2012. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on the review of administrative documentation and discussion with facility director, the facility failed to document the completion of fire drills that are required monthly.
The findings include:
The fire drill logs for the twelve months from July 2011 to July 2012 period were reviewed on August 1, 2012. The facility did not conduct fire drills, for the months of October 2011, January 2012, and February 2012 inclusive.
This finding was confirmed with the Facility Director on August 1, 2012.
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Plan of Correction
The facility director will retrain the facility staff on the appropriate completion of the fire drill procedures on 8/24/2012. The facility director will monitor compliance on 8/31/2012 to ensure the fire drills were completed and documented appropriately. The corporate compliance officer will monitor the fire drill log monthly beginning on 8/31/2012 to ensure ongoing compliance. |