Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on August 10, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Retreat at Lancaster County PA, LLC 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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Observations
Based on a review of fire drills from July 2019 until June 2020, the facility failed to conduct a sleeping hour fire drill that was due in December 2019.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Safety Director was informed by Chief Clinical Officer to ensure a sleeping hour fire drill is conducted every six months. The Safety Director understood and will ensure this is conducted for September 2020. Within 6 months of September 2020, another sleeping hour fire drill will be held. The Chief Clinical Officer will monitor at the monthly Safety meeting to ensure this is in compliance. |