INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 14, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection Peace Valley Recovery LLC 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) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's April 2024 through April 2025 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.
The facility's hours of operation are reported as Monday, Wednesday, Thursday from 8:00am to 9:00pm and Tuesday, Friday from 8:00am to 4:00pm. All the fire drills reviewed were conducted at 11:00am and there were no drills conducted during the facility's afternoon or evening hours of operation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Peace Valley Recovery will ensure that fire drills are conducted at different times each month, ensuring that they are done during both daytime and evening shifts. This will be ensured by lead tech supervisor and COO. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of a physical assault/threat by staff or a client.
While being transported by facility staff, a verbal altercation between two clients occurred on 7/18/2024 and as a result, one of the clients pulled a knife and threatened the other client. This incident was reported to the project and facility directors but was not reported to the Department at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Peace Valley Recovery will ensure that all incident reports that meet criteria for unusual incident reports will be reported to the Department within 3 business days, including physical assault/threat by staff or a client. |