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 April 27, 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, Clear Concepts Counseling 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) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of 12 fire drills from January 2019 through December 2019, the facility failed to document unannounced fire drills at least once a month. There was no fire drill documented in September 2019. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. The staff will conduct unannounced fire drills every month and documented on the fire drill log by the employee who conducted the fire drill. This standard was reviewed with the staff via an email discussion on May 1 2020. (Due to COVID-19 we have not be able to conduct face to face staff meeting so we have been communicating with staff via email and/or text messages).
The Project Director will review the fire drill logs to ensure the correct completion of the fire drill and fire drill logs are conducted and documented to meet this standard.
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of 12 fire drills from January 2019 through December 2019, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts. Six out of the twelve fire drills were conducted on Mondays.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. The staff will conduct unannounced fire drills every month. Our facility will conduct fire drills on different days and times of the week and documented on the fire drill log by the employee who conducted the fire drill. This standard was reviewed with the staff via an email discussion on May 1 2020. (Due to COVID-19 we have not be able to conduct face to face staff meeting so we have been communicating with staff via email and/or text messages).
The Project Director will review the fire drill logs to ensure the correct completion of the fire drill and fire drill logs are conducted and documented to meet this standard.
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