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 31, 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, Project Transition, Inc. - Andorra 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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Observations
Based on an administrative review of the August 2019 through June 2020 fire drill logs, the facility failed to conduct unannounced fire drills for the months of March 2020 through June 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The findings were reviewed with the Project Director and Facility Director. Project Transition's physical location was not open during the months of March 2020 through June 2020 due to the COVID-19 pandemic. Project Transition has since opened the office back up and has resumed conducting monthly fire drills. In the future, if an exception is needed, the Quality Department will file an exception with the Department of Drug and Alcohol. The PT Andorra Program Director will ensure that fire drills are conducted on a monthly basis. The Director of Residential Programs will review fire drills on a monthly basis to ensure that they are occurring. |