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 August 25, 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, New Direction Treatment Services 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 the review of the November 2019 through July 2020 fire drill logs, the facility failed to document on their written log which exit routes were used and whether the fire alarm or smoke detectors were operative for all fire drills conducted.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9-08-2020, staff responsible for conducting the monthly fire drills have been reminded to document the exit used by staff and clients to evacuate the building. The record of each fire drill will also document that the fire alarm or smoke detectors were operative for all fire drills conducted.
Ongoing compliance will be monitored by the Program Director by regular review of the monthly fire drill log. |
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 the review of the November 2019 through July 20202 fire drill logs, the facility failed to set off a fire alarm or smoke detector for all fire drills conducted.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning on 9-01-2020, during each monthly Fire Drill, the person conducting the fire drill will set off the fire alarm and document that it has been operative during the monthly drill.
The Project Director will obtain Governing Body approval to submit a request for an exception to Department Regulation 705.28.(d)(7) that requires the facility to set off the fire alarm or smoke detector during each monthly Fire Drill during thee next scheduled Board meeting. Upon approval of the Board, the Project Director will submit the request for an exception to the regulation. Pending exception approval, the alarm/smoke detectors will be tested monthly to verify and document operation during the monthly drill.
Ongoing compliance will be monitored during the Program Director's review of the monthly Fire Drill Log.
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