INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 17, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, CleanSlate Medical Group of Pennsylvania, LLC - Bethlehem 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:
|
Plan of Correction
|
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on the review of fire drill logs from June 2022 through June 2023, the facility failed to conduct an unannounced fire drill at least once a month. There was no documentation of a drill for September and November 2022. The findings were were reviewed with facility staff during the licensing process.
|
Plan of Correction
CleanSlate Centers has developed a process for oversight, monitoring & auditing to ensure ongoing compliance with documented performance of unannounced monthly fire drills via collection & verification of completed drill report log forms.
This process will mitigate future occurrence of incomplete or missing monthly fire drills for each of our licensed facilities in the state Pennsylvania.
|