INITIAL COMMENTS
|
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.
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.
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 May 8, 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, MinSec Treatment 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:
|
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 an administrative review of the July 2019 through April 2020 fire drill logs, the facility failed to conduct an unannounced fire drill during the month of March 2020.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Facility Director will create/update fire drill schedule to include a fire drill for each month of the year. The fire drills will be placed on the facility director's outlook calendar, monitored, and signed off by the facility director each month to assure fire drill was conducted and documented correctly. |
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.
|
Observations
Based on an administrative review of the July 2019 through April 2020 fire drill logs, the facility failed to document, on the April 2020 log, the number of persons in the facility at the time of the fire drill.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On May 15, 2020 Facility Director will conduct a training with all staff on how to conduct and document a fire drill.This training will include but not be limited to the documentation of the number of persons in the facility at the time of the fire drill. Upon hire and yearly training will be conducted by facility director on fire drill procedures. These training will be documented in the staff meeting minutes. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on an administrative review of the July 2019 through April 2020 fire drill logs, the facility failed to set off a fire alarm or smoke detector during the July 2019, the September 2019 and the October 2019 fire drills.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
On May 15, 2020 Facility Director will conduct a training with all staff.This training will include but not be limited to the proper procedures and documentation of conducting a fire drill. Upon hire and yearly training will be conducted by facility director on fire drill procedures. These training will be documented in the staff meeting minutes. |