INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 22, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab Management Inc., 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) (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 upon the review of administrative documentation and the facility's fire drill log, the facility failed to document that it set off a battery operated smoke detector during fire drills conducted in six of six months.
The findings include:
Site specific administrative documentation and the facility's fire drill log were reviewed on March 22, 2013. The facility presented a letter from The Department of Drug and Alcohol Programs, dated August 15, 2012, which gave the facility approval to utilize a battery operated smoke detector during fire drills. A review of the facility's fire drill log for the time frame of September 2012 to February 2013 revealed that the facility failed to document that the smoke detector was activated during fire drills conducted at the following times:
September 12, 2012 at 2:30 PM; October 12, 2012 at 6:00 PM; November 11, 2012 at 10:00 AM; December 6, 2012 at 2:00 PM; January 18, 2013 at 7:00 PM; February 25, 2013 at 4:00 PM
The Site Director confirmed the findings during the exit interview.
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Plan of Correction
The site director will have a fire drill monthly and test battery operated detectors as well as document if the batteries are working or need to be changed, effective for the month of April 2013. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based upon the review of site specific administrative documentation, the facility failed to provide through written agreement with a licensed hospital or physician, for 24-hour emergency medical coverage.
The findings include:
Site specific administrative documentation was reviewed on March 22, 2013. The facility failed to present documentation of written agreement with a licensed hospital or physician, for 24-hour emergency medical coverage.
The site director confirmed that the written agreement for 24-hour emergency medical coverage had expired prior to the inspection.
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Plan of Correction
The site director for RAW NE office will get an agreement signed by a licensed hospital or physician for 24 hour emergency medical coverage in which our facility can use as needed by 4/24/13 and place a copy in the staff development book. The agreement will be checked annually to make sure the services are still available. |