This report is a result of a complaint investigation conducted on March 30, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Gaudenzia, Inc. Broad Street were unsubstantiated. However, during the complaint investigation, it was determined that the facility was not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on April 9, 2010.
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Plan of Correction
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Observations
Based upon a review of the facility shift log and an interview with the facility's Program Administrator, both occurring on March 30, 2010, the facility failed to conduct unannounced fire drills at least once per month.
The findings include:
A note in the staff communication log book entered on March 3, 2010 stated the following:
"Please check the calander [sic] in the first floor conference room to see if you are scheduled to do a fire drill."
When asked where the facility kept the schedule for the fire drills, the Program Administrator said that it was to be posted on the wall of the conference room. When asked who all had access to the schedule the Program Administrator stated that all staff see it.
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Plan of Correction
On a monthly basis, the Program Supervisor will conduct an unannounced fire drill.
The unannounced monthly fire drill will be conducted by the Program Supervisor, on the 1st Shift (8:00 AM ? 4:00 PM), who will first contact the Fire Alarm Company to place the system on bypass and conduct the fire drill. The staff on duty will record any and all pertinent information as it relates to the fire drill in the Fire Drill Log Book.
When the fire drill is conducted on the 2nd Shift (4:00 PM ? 12:00 AM) or 3rd Shift (12:00 AM ? 8:00 AM), the Program Supervisor will telephone the facility directing the staff on duty to conduct a fire drill on the spot, following the above instructions, i.e., contact the Alarm Company, and document the outcome in the fire Drill Log Book. In all instances, the fire drill will be conducted spontaneously and sporadically at the discretion of the Program Supervisor on a monthly basis.
The Director will monitor the fire drills to ensure that the procedure will be followed according to the applicable chapters of 28 PA Code which pertain to the facility. |