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 25, 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, Caron Outpatient Services 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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705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on the review of the eight fire drill logs conducted on August 25, 2020, the facility failed to conduct fire drills during normal staffing hours. Three fire drills were conducted on Fridays during which time the facility is not open per the hours of operations submitted. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure all fire drills are conducted during normal business hours beginning with September's fire drill. The Risk Management Department will monitor completion of monthly fire drills and documentation of drills to ensure compliance with the regulation. |
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.
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Observations
Based on the review of eight fire drill logs conducted on August 25, 2020, the facility failed to maintain a written fire drill record that includes exit routes used and whether the fire alarm or smoke detector was operative. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director at the facility will utilize different exit routes when conducting fire drills and will document exit route used on fire drill log. The Risk Management Department will review drill logs on a monthly basis to ensure the facility is utilizing and documenting alternate exit routes.
Currently program leases a single suite in a multi-use office building therefore we are unable to sound the alarm for the entire building when conducting a drill. The Corporate Director of Compliance, Quality & Risk at Caron will submit a letter of exception to the Department requesting an exception to the requirement for sounding the alarm for the entire building. Caron is requesting to utilize a local alarm that will only alert patients and staff in our suite. Caron has purchased a battery-operated smoke detector to utilize when conducting fire drills. This smoke detector was tested on 9/22/20 and is able to be heard in all areas of the suite. The Executive Director at the facility will immediately begin utilizing the battery-operated smoke detector to conduct fire drills. A fire drill will be conducted by 9/29/20 utilizing this battery-operated smoke detector.
In addition, Caron will contact the building landlord to discuss alternative options for setting off the alarm for the building during fire drills. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of eight fire drill logs conducted on August 25, 2020, the facility failed to prepare alternate exit routes to be used during fire drills.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure to utilize different exit routes when conducting fire drills and will document exit route used on fire drill log beginning with September's fire drill. The Risk Management Department will monitor completion of monthly fire drills and documentation of drills to ensure compliance with the regulation. |
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.
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Observations
Based on the review of eight fire drill logs conducted on August 25, 2020, the facility failed to document that a fire alarm or smoke detector was set off during each fire drill.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Currently program leases a single suite in a multi-use office building therefore we are unable to sound the alarm for the entire building when conducting a drill. The Corporate Director of Compliance, Quality & Risk at Caron will submit a letter of exception to the Department requesting an exception to the requirement for sounding the alarm for the entire building. Caron is requesting to utilize a local alarm that will only alert patients and staff in our suite. Caron has purchased a battery-operated smoke detector to utilize when conducting fire drills. This smoke detector was tested on 9/22/20 and is able to be heard in all areas of the suite. The Executive Director at the facility will immediately begin utilizing the battery-operated smoke detector to conduct fire drills. A fire drill will be conducted by 9/29/20 utilizing this battery-operated smoke detector.
In addition, Caron will contact the building landlord to discuss alternative options for setting off the alarm for the building during fire drills.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of seven personnel records on August 25, 2020, the project failed to prepare an annual written individual staff performance evaluation, copies of which shall be reviewed and signed by the employee.Employee # 7 did not have documentation of an annual written individual staff performance evaluation for the 2019 year. The evaluation submitted was dated August 13, 2018.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The annual performance evaluation for Employee #7 for FY20 will be completed by September 25, 2020. Human Resources will regularly monitor the completion of employee performance evaluations to ensure evaluations are completed on an annual basis by the required due date. |