INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 21-23, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Dolminis 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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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 staff schedule work hours and CPR certification cards, the facility failed to provide a sufficient number of staff persons trained in CPR so that at least one person trained in these skills is onsite during the project's hours of operation.
The findings include:
The CPR certification cards were reviewed on August 31-September 1 and September 21-23, 2015. The facility's weekend hours are staffed by nursing and rotating clinical staff. The facility nurses current CPR training was completed on line and did not include hands on instruction. There was no documentation of current CPR certification of the nursing staff. The clinical staff schedule was reviewed for May- August of 2015. Clinical staff with no documentation of CPR certification were on duty May 9 and 10, June 6, 7, 20, 21 27 and 28, July 25 and 26, August 8, 9, 22 and 23, 2015. There was no documentation that at least one person trained in CPR was onsite during the project's hours of operation for these dates.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A full CPR certification training is scheduled for 10/27/15. All staff who are not currently CPR certified or have a certification of completion with no expiration date are scheduled to attend this training. There will be at least 1 staff member with full CPR certification on duty at all times when clients are in the building. Program director, clinical supervisor and the human resource department will track and monitor when trainings are due and when completed. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on the review of the fire drill logs, the facility failed to conduct fire drills during normal staffing conditions for two of twelve months.
The findings include:
Fire drill logs were reviewed on September 21-23, 2015. Fire drills, conducted on December 30, 2014 and June 30, 2015, were conducted after business hours and outside of normal staffing conditions by building personnel. There were no staff or clients in the building at the time of the drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All fire drills will be conducted during normal staffing hours. Next fire drill will occur by October 31, 2015. Compliance will be monitored by the risk leader, maintenance staff and program director. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on the review of client records, the facility failed to document that verbal medication orders were put in writing and signed by the prescribing physician within three business days from the time the order was given, in one of one client record.
The findings include:
Fourteen client records were reviewed on September 21-23, 2015. One of the fourteen client records documented verbal orders. The facility did not document that the verbal orders were signed by the prescribing physician within three business days from the time the order was given in client record # 6.
Client # 6 was admitted on October 30, 2014. Verbal orders, dated 8/13/15, 8/14/15 and 9/14/15, signed by the prescribing physician, did not document the date and time of the physician's signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
NTP physician will sign off, date and time all verbal orders within 72 hours beginning immediately.
Nursing staff will ensure compliance during random monthly medical chart audits.
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