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.
Part 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.
Part 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 April 7, 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, The Children's Service Center of Wyoming Valley 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 facility fire drills from April 2019 - March 2020, the facility failed to conduct unannounced fire drills at least once a month.
There was no fire drill conducted during the month of November 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
After review of this citation, a fire drill was conducted on 11/13/2019, but was missed when completing the logs for each location. The facility director will review all fire drill logs on a biweekly basis for the next 6 months to ensure that all fire drills are being captured accordingly. This effort will eliminate any future documentation errors. |