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 May 18, 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, UPMC Behavioral Health of the Alleghenies 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
A review of the June 2019 through April 2020 fire drill logs was conducted during Part 1 of the annual licensing inspection. The facility failed to document the exit routes used during the August 16, 2019 and December 23, 2019 fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Officer will revise the fire drill form to include all exits to be listed out during the drills as well as a signature line for the supervisor for the Safety Officer's signature, Rebecca Eger, Admin.Coordinator by June 1, 2020. Fire drill forms will be reviewed monthly by said supervisor.
All Safety Officers will be reeducated on the new form and how to complete it by June 30, 2020, by their supervisor Rebecca Eger, Admin. Coordinator. |