INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 31, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Resolutions Recovery Center, 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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705.10 (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 drill logs, the facility failed to conduct unannounced fire drills at least once a month.
Fire drills were reviewed from February 2024 through February 2025. There was no documentation of any fire drill conducted for the month of February 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
CEO has completed 99% of all fire drills and fire drill responsibilities in the past. The responsibilities of the monthly fire drills will be distrusted to the Program Technician Supervisor, the Assistant Program Technician Supervisor, and the Program Director. This will help ensure that the required monthly fire drills will be completed with a check and balance system.
Program Director will monitor to ensure that more than one staff is conducting and monitoring fire drills, it is not the same person each month. Program Director will monitor to ensure log is properly being filled out and the information in the log is acuate.
Program Technician Supervisor and Program Technician Assistant Supervisor will conduct the correct type of fire drill monthly. Correct fire drills include awake fire drill, live fire drill and sleeping hours fire drill. Staff members will be alternated to complete fire drills for each shift.
The fire drill log has been updated to include awake fire drill sheets, sleeping hours fire drill sheets, and live fire drill sheets. The update includes a specific monthly order when an awake fire drill sheet, sleeping hours fire drill sheet, and live fire drill sheet needs to be completed. This will stop human error from occurring on which type of fire drill will need to be completed month to month (a check and balance system).
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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 drill logs, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
Fire drills were reviewed from February 2024 through February 2025. A fire drill was conducted during sleeping hours on March 11, 2024. Another sleeping drill would have been due no later than September 11, 2024; however, there were no further fire drills documented during sleeping hours.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill log has been updated to include awake fire drill sheets, sleeping hours fire drill sheets, and live fire drill sheets. The update includes a specific monthly order when an awake fire drill sheet, sleeping hours fire drill sheet, and live fire drill sheet needs to be completed. This will stop human error from occurring on which type of fire drill will need to be completed month to month (a check and balance system).
Program Director will monitor to ensure that more than one staff is conducting and monitoring fire drills, it is not the same person each month. Program Director will monitor to ensure log is properly being filled out and the information in the log is acuate. Program Director will monitor that each fire drill is scheduled and followed through by the Program Technician Supervisor and/or Program Technician Assistant Supervisor is completing the scheduled fire drill.
Program Technician Supervisor and Program Technician Assistant Supervisor will conduct the correct type of fire drill monthly. Correct fire drills include awake fire drill, live fire drill and sleeping hours fire drill. These fire drills have been added to the log to reduce error in what type of fire drill needs to be completed for that month. Staff members will be alternated to complete fire drills for each shift. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of administrative information, the facility failed to inspect medication storage areas in compliance with State and Federal laws and program policy.
Facility policy and procedures indicate inspections are to be completed monthly.
The timeframe for review was April 2024 through March 2025. There was no medication storage area inspection documented for October 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The nursing checklist log was reviewed by one nursing staff member. A check and balance system has been implemented. The medication log will be reviewed by nursing staff members, Medical Director, Program Director, and CEO to ensure completion of monthly inspection of medication is properly completed and documented.
Nursing staff will continue to complete the monthly nursing checklist log. Once completed the log will be reviewed by Medical Director, Program Director and CEO to ensure completion. Once the log has been properly filled the nurse will give the log to the Medical Director, Program Director and CEO to be reviewed. This review will take place during the daily interdisciplinary team meetings. Medical Director, Program Director, and CEO are present each day at these meeting. |