This report is a result of an onsite follow-up inspection regarding the plans of correction for the November 6, 7, 8 and 9, 2012 licensure renewal inspection. The follow-up inspection was conducted on June 24-25, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Pennsylvania Care LLC d/b/a Miners Medical 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 the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
A review of the fire drill logs was conducted on June 24, 2013. The fire drills conducted from November 2013 - June 2013 were reviewed. The facility did not document any exits used during fire drills for January 15, 2013, May 10, 2013, and June 21, 2013. The other three months all had the front door as the means of egress from the facility during the fire drill.
The facility failed to document alternate exits routes being used during fire drills.
The alternate exit findings were reviewed with the project director on June 24, 2103 and was not disputed.
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Plan of Correction
The facility failed to comply with Observation#P281 requiring documentation for exits used during fire drills conducted on January 15, 2013, May 10, 2013, and June 21, 2013. The facility also failed to comply with utilizing alternate fire exit routes.
It is the responsibility of the Facility Director and in the absence of the Facility Director, Clinical Staff will be responsible for properly conducting fire drills by means of utilizing alternative egress routes used and all exits utilized will be properly documented. This POC will be commenced for the July 2013 fire drill.
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