INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and complaint investigation conducted on February 13-15, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Roxbury 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 the inspection.
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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 facility records conducted as part of the presubmission process, and during the onsite inspection, the facility failed to ensure that there were sufficient staff certified in first aid training to cover all hours of operation.
The facility did not have persons with documented first aid certification scheduled to cover the following days and times:
*01/01/2017 from 7:00PM to 11:59PM
*01/02/2017 from 12:00AM to 6:29 AM, 3:00PM to 11:59PM
*01/03/2017 from 12:00AM to 10:29PM
*01/04/2017 from 3:00PM to 6:29PM
*01/05/2017 from 3:00PM to 6:29PM
*01/06/2017 from 3:00PM to 6:29PM
*01/07/2017 from 7:00PM to 11:59PM
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
For staff members that are currently employed, the Director of Human Resources and Director of Nursing will ensure that all nursing staff members are trained in first aid to cover all hours of operation. Employees within other facility departments who have not already received first aid training will be trained in first aid at the time of their CPR recertification. The Director of Human Resources will ensure that all future employees receive both CPR and first aid training during new hire orientation. |