INITIAL COMMENTS
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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 1, 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, Carolyn Mottor-Rivera Counseling 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) (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 the fire drill logs provided, the facility failed to maintain a fire drill log that includes the number of persons in the facility at the time of the drill and whether the fire alarm or smoke detector was operative.These were reviewed with the facility during the licensing process.
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Plan of Correction
705.28(d) (4)
The director has reviewed the written fire log. The fire log meets requirements except the citation notations. The director has made the following changes to the fire log that includes a column was added to the fire drill that documents the number of persons in the facility at the time of the fire drill; and a column was added to the fire drill log to include whether the fire alarm or smoke detector was operative at the time of the fire drill.
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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 twelve fire drills conducted by the facility from July 2019 to June 2020, the facility failed to set off a fire alarm or smoke detector during each fire drill. Eleven of the fire drills used a verbal method of communication and only one tested the fire alarm. These findings were reviewed with the facility during the licensing process.
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Plan of Correction
705.28 (d) (7)
The director has reviewed 705.28. Fire safety (d) Fire drills. The director has changed the method of notification to a smoke detector that was purchased from CVS Pharmacy until request is submitted and approved by DDAP for an alternate means to setting off an alarm or smoke detector to alert each person at the facility the need to evacuate the building.
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