INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 12, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Central Montgomery MH/MR 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 a review of the facility's fire drill log, the facility failed to maintain a written fire drill record that included the number of persons in the facility at the time of the drill and whether the fire alarm or smoke detector was operative. The facility failed to prepare alternate exit routes and failed to conduct fire drills at different times of the day and night and on different staffing shifts.The findings include:On August 12, 2014, the facility's fire drill log was reviewed covering the period of September 26, 2013 through July 31, 2014. The facility failed to maintain a written fire drill record including the number of persons in the facility at the time of the drill and whether the fire alarm or smoke detector was operative. In addition, the facility failed to prepare alternate exit routes and failed to conduct fire drills at different times of the day and night and on different staffing shifts. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director has reviewed current fire drill procedures and log. As of today, 9/9/2014, this facility has an updated log, which will document changes to fire drill procedures, including: the amount of staff and consumers in/exiting building, time of day the drill occurred(which includes documented drills at different times of operating hours), documentation that smoke detectors are tested and operative. These documents will be stored in the agencies Fire Drill Log and reviewed in supervision and quarterly meetings with CORE staff. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of administrative documentation, including the 2013 annual report, the governing body failed to make available to the public an annual report that included a financial statement of income and expenses. The findings include:The administrative documentation was reviewed on August 12, 2014. The governing body made the 2013 annual report available to the public on July 16, 2014; however, the annual report did not include a financial statement of income and expenses.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director and Program Director have consulted with the CFO (interim) of Central Montgomery MH/MR Center and assured that financial statements and expenses will be added to the Annual Report that will be made public in December 2014. Copy of this report will be kept both electronically and on hard copy (in an annual statistics log). |