INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 19, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Deerfield Center for Addictions Treatment 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 and a plan of correction is due on April 18, 2008.
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Plan of Correction
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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 a review of the fire drill log, the approval letter from the Division of Drug And Alcohol Program Licensure, and conversations with the clinical supervisor on March 17, 2008, March 19, 2008 and March 20, 2008, the facility failed to provide documentation to show the fire alarm/smoke detectors are operable. This is a requirement included in the letter giving approval to forgo activation of the fire alarms during the monthly fire drills.
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Plan of Correction
The Program Director will contact the owner of the building to see if there is documentation that the fire system is inspected annually. If such documentation is available, a copy of the latest inspection will be requested and added to the fire log. If such documentation does exist, a request will be made to the owners of the building to manually set off the fire alarm to ensure that it works properly and documentation will be added to the Fire Log. The owner will be contacted within the next three weeks by the Program Director. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on the review of the policy and procedure manual on March 17, 2008, the facility failed to provide a policy for follow-up on clients who do not successfully complete treatment.
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Plan of Correction
The Program Director will update the current follow-up policy to include a follow-up process to be used for clients that leave treatment prematurely. The policy was updated as of 03/24/2008 and was implemented on April 1, 2008. |