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.
Part 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.
Part 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 12, 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, Drug and Alcohol Rehabilitation Services, Inc 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) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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
Based on a review of nine fire drills from October 2019 through July 2020, the facility failed to maintain a written fire drill record including the exit route used and whether the fire alarm or smoke detector was operative.
The fire drill dated July 31, 2020 had no exit route documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Manos House Program Director will oversee that each fire drill record indicates whether the fire alarm or smoke detector was utilized for the fire drill. This will be attested by the DARS.,Inc. Executive Director.
The Fire Drill record form was adjusted to easily indicate the exit route used and will be verified by the Program Director prior to final approval of the fire drill record. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of nine fire drills from October 2019 through July 2020, the facility failed to set off a fire alarm or smoke detector during each fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Manos House Program Director edited the Fire Drill Record indicating that a 24 hour monitoring service (Able Security)is utilized to insure that our entire fire emergency system operation is fully functional. If there is an error in fire system, the Executive Director, DARS Maintenance, and the On-call staff are notified immediately for corrective action. Also, the fire drill record will indicate during the scheduled fire drills that the drill was placed on a test mode so the fire alarm can be used without dispatching the emergency services. |