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.
Part 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.
Part 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 May 22, 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, Gaudenzia, Inc. Outreach 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 the review of the April 2019 through April 2020 fire drill logs, it was determined that the facility failed to conduct unannounced fire drills during normal staffing conditions. The fire drills for the months of June 2019 and November 2019 were conducted at times that were outside of the facility's scheduled hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective June 8, 2020, Program Supervisor will ensure that fire drills will occur twice per month (once per shift). All fire drills will be completed and maintained in Fire Drill Log Book that will be kept in the Program Supervisor's office. Division Director will ensure that fire drills are being completed. Additionally, the CQI Department will conduct quarterly onsite inspections which will include review of fire drills/reports. |