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 20, 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, Carbon Monroe Pike Drug and Alcohol Commission 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 the review of four fire drill logs conducted on August 20, 2020, the facility failed to conduct unannounced fire drills at least once a month. The facility failed to conduct fire drills in March and April 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills will be completed by Outpatient supervisor on a monthly basis, even in the event that the office is closed for an extended period of time. |
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 four fire drill logs conducted on August 20, 2020, the facility failed to maintain a written fire drill record that included exit routes used, problems encountered 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
Fire drill logs have been changed to reflect a designated column for exits routes used, that fire alarms and smoke detectors were operable/checked, and to note any issues/ problems during the fire drill. Outpatient supervisor will complete logs. |
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 four fire drill logs conducted on August 20, 2020, the facility failed to prepare alternate exit routes to be used during fire drills in the four fire drills submitted.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire logs have been changed to include specific exits used during all fire drills, which will clearly delineate that alternative exits were used during fire drills. The Outpatient Supervisor will conduct the monthly drills, using alternate exit routes. The Facility Director will be responsible for the oversight of alternative exits being used during monthly drills and that the fire logs indicate such. |
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 four fire drill logs conducted on August 20, 2020, the facility failed to set off a fire alarm or smoke detector during each fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An exception letter for the use of an air horn during all fire drills was completed and will be submitted to DDAP. The exception request is due to sharing building space with other agencies and to avoid the local fire department being dispatched monthly for our fire drills. Meanwhile, and if exception is not approved, a battery-operated smoke detector alarm will be purchased and installed by 9/2/2020. It will be set off to signify the fire drill, by the Outpatient Supervisor who is conducting the monthly fire drills. |
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 eight personnel records on August 20, 2020, the facility failed to prepare an annual written individual staff performance evaluation, copies of which shall be reviewed and signed by the employee.
Employee # 1 ' s last dated annual written individual staff performance evaluation was June 2019, there was no documentation provided for June 2020 at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Annual individual staff performance evaluation due dates will be part of the agenda items during administration/ QA meetings to make sure all are completed on a timely basis. The Administrative Officer will reach out to the Board Personnel Committee, who completes the Director's annual evaluation, to ensure they know the due date and to have it completed by the due date. This evaluation was strictly COVID-related, as this delayed the Board's Personnel Committee needing to virtually schedule to complete this task. It has since been completed. |