INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 23, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Rehab After Work 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) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of the March 2022 through January 2023 fire drill logs, the facility failed to conduct fire drills during normal staffing conditions for the drills conducted during the months of June 2022, August 2022, and September 2022.
The fire drill logs for June, August, and September 2022 documented that the fire drills were conducted outside of the facility's posted hours of operation, which are Monday through Friday from 9:00AM to 9:00PM. The June 2022 fire drill was conducted at 8:00AM, the August 2022 fire drill was conducted at 7:45 AM and the September 2022 fire drill was conducted at 8:00AM.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In order to abide by DDAP regulation, safety officers and clinical supervisors with the support of clinical director, quality manager, and director of compliance will conduct fire drills at different times of the day to reflect different staffing shifts during facility hours of operation. Identified staff listed will re-train on -site staff within 30 days with full compliance expectation as of 5/28/2023. Quarterly audits will occur by quality manager and clinical director in order to ensure consistency in accordance with the regulation. |
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 March 2022 through January 2023 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts during every fire drill reviewed.
The facility's hours of operation are Monday through Friday 9:00AM - 9:00PM. All fire drills conducted, during the reviewed period, were completed from the hours of 7:45AM through 3:00PM. None of the fire drills were conducted during the facility's evening hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to abide by DDAP regulation, safety officers and clinical supervisors with the support of clinical director, quality manager, and director of compliance will conduct fire drills at different times of the day to reflect different staffing shifts during facility hours of operation. Identified staff listed will re-train on -site staff within 30 days with full compliance expectation as of 5/28/2023. Quarterly audits will occur by quality manager and clinical director in order to ensure consistency in accordance with the regulation. |