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 13, 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, Montco 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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705.28 (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
Based on the review of personnel records, the facility failed to document the instruction in the use of fire extinguishers upon employment in two of two personnel records reviewed.Employee # 1 was hired as the Project Director/Facilty Director on June 9, 2020. The fire extinguisher training was not completed until July 9, 2020.Employee # 2 was hired as a counselor on February 11, 2020. The fire extinguisher and emergency training was not completed until July 9, 2020.These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that within 7 days of hire, all staff will have completed a fire extinguisher training and that it will be documented on the Individual Training Plan. |
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
Based on the review of the September 2019 through June 2020 fire drill logs, the facility failed to conduct an unannounced fire drill for the months of September 2019, October 2019, March 2020, April 2020, and May 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Safety Officer or designee will conduct monthly unannounced fire drills and include all required items on the logs as indicated in 709.28(d)4. The Project Director will ensure that the Safety Officer will conduct the monthly fire drills. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records, the facility failed to ensure that all personnel, on all shifts, were trained to perform assigned tasks during emergencies in two of two personnel records reviewed. Employee # 1 was hired as the Project Director on June 9, 2020. The emergency training was not completed until July 9, 2020. Employee # 2 was hired as a counselor on February 11, 2020. The emergency training was not completed until July 9, 2020.These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that within 7 days of hire, all staff will have completed a fire extinguisher training and that it will be documented on the Individual Training Plan. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on the review of the September 2019 through June 2020 fire drill logs, the facility failed to include the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether fire alarm or smoker detector was operative on the logs for all months reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Safety Officer or designee will ensure that the monthly fire drill logs are completed and include all required items listed in 705.28(d)4. The Project Director will ensure that the Safety Officer is completing the fire drill log with all required items denoted. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documentation, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has submitted a request for an exemption of the requirement to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year. If the request is not granted, the project will obtain an audit of the financial statements within 90 days of receiving the decision. |