INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, 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 2, an abbreviated on-site inspection, conducted on April 9, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, God's Mountain Recovery Center, Inc was found to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Therefore, no deficiencies were identified during this inspection and no plan of correction is required.
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Plan of Correction
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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 a review of 10 fire drills reviewed, from June 2019 through March 2020, the facility failed to include problems encountered and whether the fire alarm or smoke detector were operative during the fire drill in each.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/28/20 Project Manager implemented a new fire drill log to include a section for documentation of problems encountered and documentation as to whether the fire alarm or smoke detector was operative during the fire drill. The project manager is responsible to make sure that this plan of correction is implemented. All items were rechecked by Project Director again on 4/28/2021. |
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 10 fire drills from June 2019 through March 2020, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts. Five fire drills were conducted on Tuesdays and the other five were conducted on Fridays.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff meeting was held by Project Manager on 4/27/2020 to educate staff that monthly fire drills should be conducted on different days of the week, on different times of the day, and on different staffing shifts. Project manager is responsible to make sure new standards are met. All items were rechecked and validated by Project Director on 4/28/2021. An annual review was also completed for staff. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of 10 fire drills from June 2019 through March 2020, the facility failed to set off a fire alarm or smoke detector during each fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff meeting was held by project Manager on 4/27/2020 to educate staff that during each monthly fire drill the fire alarm or the smoke detector must be set off. This will be added to the fire drill log to be documented each month. Project Manager is responsible to make sure standards are adhered to. An annual refresher on this process was completed 4/28/2021. The current logs also reflect that the alarms and detectors were set off during the test. |