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 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, RHD Family House 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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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on an administrative review of the August 2018 through April 2020 fire drill logs, the facility failed to conduct an unannounced fire drill during the months of August 2018 through March 2019.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Fire drills will be conducted monthly, with completed fire drill logs kept in a binder in the office of the assistant program manager.
The Assistant Program Manager is responsible for conducting fire drills. The director is responsible for assuring that the fire drills are conducted each month and will check the log monthly to assure that the drills were completed and appropriately documented |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on an administrative review of the August 2018 through April 2020 fire drill logs, the facility failed to set off a fire alarm or smoke detector during each fire drill conducted from April 2019 through April 2020.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The program contacted the fire department and alarm company to learn how to be able to use the fire alarm during a fire drill without it calling the fire department. The fire drill for June 2020 was conducted using the fire alarm, and each subsequent fire drill will do the same.
The assistant program manager is responsible for conducting fire drills. The director is responsible for assuring that file drills are conducted appropriately each month. |