INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 8, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Huntington Creek Recovery Center was found not 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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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical site inspection on December 8, 2020, the faciltiy failed to ensure that resident bathrooms had either individual paper towels or a mechanical dryer in each bathroom.
These findings were reviewed with faciltiy staff during the the licensing process.
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Plan of Correction
Specific Course of action: Huntington Creek Recovery Center will begin ordering and supplying paper towels to be placed for use in each resident restrooms. HCRC will add this supply to our regular order of paper products.
Means: HCRC has a vendor responsible for paper products. Paper towels are now a part of our regular order.
Persons Responsible: Facility Director and Supervisor of Facility operations. Facility director has approved added expense for ordering additional paper towels. Supervisor of Operations has been tasked with placing the order and monitoring amounts needed to keep supply in tact.
Facility is in full compliance as of 12/22/2020 (when order is delivered) |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of ten fire drills from January 2020 through October 2020 the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The only documented sleeping fire drill took place on January 31, 2020.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Specific Course of Action: Huntington Creek Recovery Center will conduct fire drills during sleeping hours at least once every 6 months.
Means: Responsible staff will be educated on the fire safety regulations per DDAP. Upcoming drills will be discussed and reviewed by safety committee to better organize regulatory needs.
Persons Responsible: Facility Director, Supervisor of operations, Risk Manager. During monthly safety committee meeting, fire drills are added to the regular agenda. Risk manager will monitor DDAP regulatory needs overall, but specifically overnight drills. This will be added to our next fire drill in order to be in full compliance.
Facility will be in full compliance: 01/05/2021 |