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 July 22, 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, Conewago-Snyder 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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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drills from August 29, 2019 until June 2020, the facility failed to conduct fire drills at least once a month for the months of September 2019, December 2019, February 2020 and March 2020.
These findings were discussed with facility staff during the inspection.
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Plan of Correction
Beginning at time of this response, 8/7/2020, the Facility Director will ensure the implementation of the following fire drill measures: (1) unannounced drills occur monthly; (2) drills cover different shifts over the quarter; (3) drills occur during varying weeks of the month from month to month; and (3) when conducted on overnight shifts the drills occur during client sleeping hours. Oversight of this process will be conducted monthly by the Facility Director and Corporate Compliance Officer. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drills from August 29, 2019 until June 2020, the facility failed to conduct fire drills during sleeping hours at least every six months. The last sleeping hours fire drill was conduct on October 26, 2019.
These findings were discussed with facility staff during the inspection.
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Plan of Correction
Beginning at time of this response, 8/7/2020, the Facility Director will ensure the implementation of the following fire drill measures: (1)
Sleeping drills will be scheduled, unannounced, and conducted at a minimum of once per 6 months time period. Oversight of this process will be conducted monthly by the Facility Director and Corporate Compliance Officer. |