INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 28, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Diakon Child, Family, and Community Ministries 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 personnel/training records, the facility failed to document that acceptable CPR training and certification was provided to a sufficient number of staff persons, so that at least one person trained in the skill is onsite during all hours of operation for the facility.
The findings include:
Six personnel/training records were reviewed on May 26, 2015. In six of six personnel records, the facility failed to document that the employee has completed acceptable CPR training and certification. The facility was unable to demonstrate that at least one staff person with acceptable CPR training and certification is onsite during all hours of the facility's operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute admission for the purposes of general liability, professional malpractice or any other court proceedings.
The Clinical Director will ensure that staff members will participate in CPR and first aid training conducted by a Diakon certified CPR/First Aid trainor at the Diakon facility located at 960 Century Drive in Mechanicsburg. The number of staff trained will be sufficient enough to cover all working hours.
Documentation of completed trainings will be kept in the staff training file. |