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 April 28, 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, Positive Pathways 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
The facility failed to maintain a written fire drill record including the exit route used and whether the fire alarm or smoke detector was operative.
The fire drill logs for the period of February 2019 - March 2020 were reviewed during the offsite inspection on April 28, 2020. The fire drills conducted in the months of February, July and October 2019 did not include documentation of an exit route. The fire drills conducted in May, June, July, August, September, October, November, December 2019 and January & February 2020 did not include documentation that the fire alarm or smoke detector was operative.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A staff training was conducted to address the deficiency. During the training, staff were shown how to properly complete the fire drill form. Specific emphasis was placed on indicating accurately that the smoke detectors are operational and used to notify those in the facility that an immediate evacuation is warranted. In addition, properly documenting exit routes every time was specifically addressed. All future fire drill logs will receive final review by the Program Director for accuracy. The Clinical Supervisor will be present for all fire drills and will also review the log before forwarding to the Program Director for final review. This will begin immediately on 5/1/2020. |
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
The facility failed to document that the fire alarm or smoke detector was set off during each fire drill.
The fire drill logs for the period of February 2019 - March 2020 were reviewed during the offsite inspection on April 28, 2020. The fire drills conducted in May, June, July, August, September, October, November, December 2019 and January & February 2020 did not include documentation that the fire alarm or smoke detector was set off during the fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A staff training was conducted to address the deficiency. During the training, staff were shown how to properly complete the fire drill form. Specific emphasis was placed on indicating accurately that the smoke detectors are operational and used to notify those in the facility that an immediate evacuation is warranted. All future fire drill logs will receive final review by the Program Director for accuracy. The Clinical Supervisor will be present for all fire drills and will also review the log before forwarding to the Program Director for final review. This will begin immediately on 5/1/2020. |