INITIAL COMMENTS
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This report is a result of an on-site initial licensure inspection conducted on October 23, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Freedom Recovery Center, LLC 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of the Staffing Requirement Facility Summary Report and an interview with the Facility Director and Clinical Supervisor, the facility failed to document that a sufficient number of staff were certified in CPR, so that at least one person trained in these skills would be onsite during the project ' s hours of operations. The findings include:The the Staffing Requirement Facility Summary Report and the interview with the Facility Director and Clinical Supervisor, was conducted on October 23, 2015. The Facility Director confirmed that current staff were not currently certified in CPR, therefore there would not be least one person trained in these skills is onsite during the project's hours of operation.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on the physical plant inspection, the facility failed to ventilate bathrooms by exhaust fan or window. The findings include:A physical plant inspection was conducted on October 23, 2015. There two women's and two men's restrooms in the facility. The women's and men's bathroom in the rear of the office did not have an operable exhaust fan or window.These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (b) (2) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(2) Place the smoke detector in a common area or hallway. All detection devices shall be interconnected.
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Observations
Based on the physical plant inspection, the facility failed to ensure that smoke detectors were interconnected. The findings include:A physical plant inspection was conducted on October 23, 2015. The facility occupies two floors of office space. There were two smoke detectors located in the facility. There was no documentation provided to show the smoke detectors were interconnected. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |