INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 4, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Milestone Centers, 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 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to document that staff were instructed in the use of the fire extinguisher upon staff employment in one of one personnel records reviewed on January 4, 2019.
Employee # 1 was employed by the D/A facility on April 1, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director obtained new training material on the use of fire extinguishers. Material will be reviewed during the next group supervision. All staff receiving the training will sign an acknowledgment form, which will be added to the personnel file. This training has been added to the list of orientation items for new employees. Personnel files are maintained and regularly audited by Human Resources.
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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
The facility failed to document unannounced fire drills at least once a month based on a review of fire drill records on January 4, 2019.
No fire drills were conducted for March and December 2018.
The fire drill records for March 2018 and April - November 2018 did not include documentation of the exit route used, problems encountered and whether or not the fire alarm or smoke detector was operative.
In addition, the facility failed to document that all personnel were trained to perform assigned tasks in emergencies based on a review of personnel record # 1.
The findings were reviewed with facility staff during the licensing process.
The monthly fire drill citation is a repeat citation from the 2018 licensing inspection.
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Plan of Correction
Project Director has developed a schedule for fire drills for the entire year. This schedule will be kept confidential to ensure that drills meet the requirement of being unannounced. The Project Director will provide the monthly date to a designee one week in advance for coordination. This new system will ensure that each month is accounted for. Additionally, a new fire drill log has been adopted that contains all necessary required elements.
The Project Director will maintain all fire drill records. They will be monitored monthly as they are performed, and then again annually as part of our overall Quality Assurance plan.
Milestone has an emergency protocol for each facility. All staff will be retrained on the emergency and evacuation protocol for this facility. We have created an acknowledgement that they will sign. This acknowledgement will be maintained in their personnel file. Personnel files are audited and maintained by Human Resources regularly.
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