INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 8, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Treatment Access and Services Center of Berks County, 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 and a plan of correction is due on January 15, 2008.
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Plan of Correction
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility ' s fire drill log, the facility failed to document alternate exit routes to be used during fire drills.
Findings:
The facility ' s fire drill log was reviewed on December 8, 2008. The facility was required to document alternate exit routes to be used during fire drills. The facility documented " stairs " as the exit route used during the last twelve monthly fire drills.
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Plan of Correction
TASC will document the existence of the alternate route and train staff in its use. TASC will use the alternative exit in some of their drills.
Documentation and training will took place January 29, 2009 at an all staff meeting. Use of the alternative exit will begin during the February fire drill.
It will be the responsibility of the Executive Director and the Management team to train the staff. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review administrative documentation, the facility failed to document a written agreement with a licensed hospital or physician for 24-hour emergency psychiatric coverage.
Findings:
Administrative documentation was reviewed on December 8, 2008. A written agreement with a licensed hospital or physician for 24-hour emergency psychiatric coverage was required. The facility did not document a written agreement for 24-hour emergency psychiatric coverage.
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Plan of Correction
TASC will secure a 24 Hour Emergency Psychiatric Service Referral Agreement with United Psychiatric.
It will be the responsibility of the Executive Director to secure the agreement with United Psychiatric.
The agreement will be in place by March 1,2009.
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