INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 12, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Bucks County Counseling 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 September 12, 2010.
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Plan of Correction
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709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records and staff interview, the facility failed to document the results of reference investigations in two of three personnel records.
The findings include:
Three personnel records were reviewed on August 12, 2010. The project director is the sole proprietor, so his personnel record does not require reference checks. There was no documentation of reference checks in personnel records #2 and 3. The project director stated he did not complete reference checks.
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Plan of Correction
Project Director has obtained and inserted into files documentation of reference checks in personnel records #2 and 3. if we hire any new staff in the future, reference checks will be obtained and included in the personnel files.
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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 fire drill records, the facility failed to document alternate exit routes used during fire drills.
The findings include:
Fire drill records were reviewed on August 12, 2010. Fire drills were conducted monthly from January 2010 through July 2010. Documentation on each month's fire drill showed the exit route used was always the front door.
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Plan of Correction
Project director will use the other door as well from now on, and will alternate the exits used during monthly fire drills. We will not use both exits during a fire drill. Rather, one exit will be blocked each time so people can determine an alternate way to exit during an emergency. |