INITIAL COMMENTS
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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 July 28, 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, Allegiance Rehabilitation Center Inc. 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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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of nine personnel files conducted on July 28, 2020, the facility failed instruct two staff members in the use of the fire extinguishers upon staff employment.
Employee #1 was hired on November 11, 2019 and should have completed the fire extinguisher training upon hire or by November 18, 2019 by the latest.
Employee #2 was hired on January 7, 2019 and should have completed the fire extinguisher training upon hire or by January 14, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff hired from today (7/30/2020) forward will complete an orientation and on boarding process in their first week of employment. The Orientation Process will include Fire Extinguisher Training. This training will be scheduled by departmental leads. Each employee will sign off on the Training Sign in sheet which will be maintained in each employee's file. The Operations Director will have oversight responsibility in ensuring that the standard remains in compliance for all new hires from 7/30/2020 forward. The facility will be in full compliance from 7/30/2020 moving forward ensuring this training occurs within the 7 day time-frame from date of hire. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of nine personnel files conducted on July 28, 2020, the facility failed to ensure that two staff members on all shifts are trained to perform assigned tasks during emergency.
Employee #1 was hired on November 11, 2019 and should have completed the emergency training by November 18, 2020.
Employee #2 was hired on January 7, 2019 and should have completed the emergency training by January 14, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff hired from today (7/30/2020) forward will complete an orientation and on boarding process in their first week of employment. The Orientation Process will include Emergency Procedures Training. This training will be scheduled by departmental leads. Each employee will sign off on the Training Sign in sheet which will be maintained in each employee's file. The Operations Director will have oversight responsibility in ensuring that the standard remains in compliance for all new hires from 7/30/2020 forward. The facility will be in full compliance from 7/30/2020 moving forward ensuring this training occurs within the 7 day time-frame from date of hire. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of six fire drill logs submitted by the facility, the facility failed to prepare alternate exit routes to be used during the drills for six fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills conducted each month will ensure that at least one primary route of exit is blocked so that individuals will need to use an alternative route in one area of the building. This will occur beginning with the July, 2020 fire drill and will continue. The Operations Director has the responsibility of ensuring that fire drills are conducted, documented (we will note alternative route used in a different color) and tracked each month. Compliance in the use of alternate routes will be in place effective 7/30/2020. |