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 August 13, 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, Gate House 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 the review of seven fire drill logs conducted on August 13, 2020, the facility failed to conduct unannounced fire drills at least once a month. The facility failed to conduct unannounced fire drills in October 2019, November 2019, December 2019, and January 2020. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.10 Fire Safety the following will be implemented:
The Clinical Director will ensure that there is at least one unannounced fire drill on a monthly basis. The monthly fire drills will be conducted on varying shifts throughout the year, regardless if the facility is vacant or not.
Director of Programs will oversee the process and ensure that the procedures are followed effective today 8/20/2020. |