INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 21, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Center for Behavioral Health - PA d/b/a Discovery House - PA 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
A review of the November 2018 through September 2020 fire drill logs was conducted during the onsite inspection on October 21, 2020. The facility failed to indicate on the fire drill logs if the fire alarm or smoke detector was operative for the October 10, 2018 and September 30, 2019 fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director will review all fire drills to ensure that all the appropriate boxes are checked before filing them in the Health and Safety binder. We will review in our quarterly Health and Safety meeting. |