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.report is a result of Part 1, an abbreviated off-site inspection, conducted on July 23, 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, Al-Assist Behavioral Health Care Center 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 an administrative review of the September 2019 through June 2020 fire drill logs, the facility failed to conduct an unannounced fire drill for the month of October 2019.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address the non-compliance of standard 705.28(d)(1): Conduct unannounced fire drills at least once a month
The Quality Assurance Manager, Site Director and the Safety/Security Officers reviewed the current policies in place for Fire Safety as it relates to the findings. In addition, we discussed how the program failed to meet the above standard. According to the agency's policy in support of this standard, unannounced fire drills are to be conducted at minimum, once a month.
To avoid any future infractions of 705.28(d)(1),the QA Department will complete a targeted audit of Fire Drills on the 25th day of each month to ensure that a Frill Drill has been conducted and all documentation has been completed and filed. In the event, the audit failed to meet regulatory standards or was not conducted by the 25th of the month, the Site Director and Safety/Security Officer will have 48-hours to complete a Fire Drill that meets all standards outlined in 705.28(d) (4).
The QA Dept. will present the findings immediately to the Chief Behavioral Healthcare Officer and any infractions will be addressed prior to the end of the current month.
Monitoring: On-going by Site Directors and QA Department.
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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 an administrative review of the September 2019 through June 2020 fire drill logs, the facility failed to document, on their log, the amount of time it took for the evacuation of the fire drill conducted in September 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address the non-compliance of standard 705.28(d) (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. The Quality Assurance Manager, Site Director and the Safety/Security Officers reviewed the current policies in place for Fire Safety as it relates to the findings. In addition, we discussed how the program failed to meet the above standard. According to the agency's policy in support of this standard, fire drills are to be documented including the following information: the date, time, amount of time it took for evacuation, exit route used, number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
To avoid any future infractions of 705.28(d)(4), the Site Director will need to sign off on all documentation related to the fire drill. The QA Department will complete a targeted audit of Fire Drills on the 25th day of each month to ensure that the documentation for the Frill Drill has been completed entirely answering all the above arears and filed in binder. In the event, the audit failed to meet regulatory standards or was not conducted by the 25th of the month, the Site Director and Safety/Security Officer will have 48-hours to complete a Fire Drill that meets all standards outlined in 705.28(d) (4).
The QA Dept. will present the findings immediately to the Chief Behavioral Healthcare Officer and any infractions will be addressed prior to the end of the current month.
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