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 July 31, 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, Retreat at Lancaster County PA, 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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Observations
Based on a review of fire drills from July 2019 until February 2020, the facility failed to conduct announced fire drills for the month of March, April, May and June 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The fire drills were not conducted due to the building being closed during the COVID 19 pandemic. The building is partially open for limited staff and no patients. The staff on site will conduct a monthly fire drill and there was one conducted on July 28 and one is planned for August 2020. The Safety Director was informed by the Chief Clinical Officer to ensure a monthly fire drill is conducted and recorded. The CCO will monitor for compliance via Monthly safety meetings. |