INITIAL COMMENTS
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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 6, 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, Avenues Recovery Center of Lake Ariel, 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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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the October 2019 through June 2020 fire drill logs, the facility failed to conduct an unannounced fire drill for the month of November 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
There were no staff in the building in November as outlined on the staffing summary report so a fire drill was unable to be conducted. Moving forward, the Operations Manager will ensure that there is an unannounced fire drill done on a monthly basis. This will not be a problem as staff is now hired and clients are now residing with Avenues. The Operations Manager will continue to be responsible for this. |
705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on a review of the October 2019 through June 2020 fire drill logs, the facility failed to conduct fire drills during different staffing shifts. The facility is residential and provides services 24 hours/7 days a week; however, there were no fire drills conducted on Saturday or Sunday during the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager will be responsible for ensuring that fire drills are conducted on weekends and continue to be done on different shifts. The Facility Director will provide oversight on ensuring this gets completed during monthly check ins with the Operations Manager. |