INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 20 - 21, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Milestone Rehabilitation, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to have documented training plans in two of two personnel records.
The findings include:
Two personnel records were reviewed on May 20, 2013. The training year starts January 1, 2013 and ends December 31, 2013. At the time of the inspection there was no training plans in client records #1 and 2. An interview with facility staff on May 20, 2013 confirmed the findings.
Employee #1 was hired October 10, 2012 and as of the date of the inspection there was no training plan for review.
Employee #2 was hired October 10, 2012 and as of the date of the inspection there was no training plan for review.
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Plan of Correction
The facility will ensure that training plans will be developed and stored in personal records for each calendar year. It shall be the duty of the Project Director of creating staff training and development plans, which will include tine and locations, to comply with this regulation effective June 1, 2013 |
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 the review of personnel records, the facility failed to ensure that they have a sufficient number of staff who is first aid/CPR certified.
The findings include:
Two personnel records were reviewed on May 20, 2013. The facility failed to ensure that there was a sufficient number of staff who is trained in first aid and CPR. Employee #1 has the required CPR certification but failed to show that he had his first aid certification. An interview with facility staff on May 20, 2013 confirmed the findings.
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Plan of Correction
The First Aid training will be completed by attending the training provided by American Heart Association on July 3d, 2013. Two existing employees are registered for the training. The Project Director is responsible to make sure there is a sufficient number of staff avai;able on site who is trained in First Aid and CPR. |
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 a review of the fire drill record, the facility failed to document two monthly fire drills.
The findings include:
The fire drill record was reviewed on May, 20, 2013. The record was reviewed from November 2012 to April 2013. Two of those six months did not document that a fire drill was conducted. November 2012 and December 2012 were the two months that did not document fire drills. This was confirmed with the director on May 20, 2013.
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Plan of Correction
The Office Manager will be documenting fire drills as conducted. The Office manager will file reports on fire drill and submit the copy to the Project Director as completed. The Project Director will keep copies of all fire drill records in his files and will be responsible to monitor the frequency of fire drills as well as the completion and appropriateness of these records. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill records, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
The fire drill record was reviewed on May 20, 2013. The fire drills conducted from November 2012 - April 2013 were reviewed. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. The facility did not document any alternate exits used during fire drills. The exit route used during the fire drill was not documented for the drills conducted in January 2013, February 2013, March 2013 and April 2013. There was no documentation of fire drills conducted for the months of November 2012 and December 2012. It is unable to be determined if alternating exits were used.
An interview with facility staff on May 20, 2013 confirmed the findings.
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Plan of Correction
The facility has 2 exit routes to use during fire drills. The Project Director or his designee responsible for fire drills will be reporting which exit is used during the fire drill. Fire drills will be conducted making sure alternate exits are used in the same frequency. The reporting form on fire drills has been revised to reflect the specific exit used. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the fire drill records, the facility failed to document the time of the drills during fire drills.
The findings include:
The fire drill record was reviewed on May 20, 2013. The fire drills conducted from November 2012 - April 2013 were reviewed. The facility did not document the time during fire drills. The time of the drills was not documented for the drills conducted in January 2013, February 2013, March 2013 and April 2013. There was no documentation of fire drills conducted for the months of November 2012 and December 2012.
An interview with facility staff on May 20, 2013 confirmed the findings.
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Plan of Correction
The Project Director or his designee will be recording times during fire drills effective June 1st, 2013. The reporting form has been revised to reflect time during fire drills. |