INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 26 through 27, 2009 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 and a plan of correction is due on November 18, 2009.
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Plan of Correction
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on review of personnel records and staff interview the facility failed to ensure that the Facility Director acquired the required training hours.
The findings include:
Based on the review of personnel record #1 it was determined that the Facility Director did not obtain the required 12 hours of annual training. Also, an interview with the Facility Director confirmed that the hours were not obtained.
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Plan of Correction
The program director will have obtained the required training hours for the 2009 training year by November 17, 2009. Program director will obtain all training hours required annually.
The above will be monitored by human resources and the program director through training documentmetation and employee file audits. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on review of the facilities fire drill log the facility failed to document monthly fire drills.
The findings include:
Based on the review of the fire drill log on October 26, 2009, the facility failed to document a fire drill for the month of March 2009.
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Plan of Correction
A fire drill was not completed in March. All fire drills will be completed monthly by maintenence or clinical supervisor.
The above will be monitored by the program director, maintenance staff,the risk committee and the clinical supervisor through monthly documentation. To begin immediately. |