INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection on May 22, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, God ' s Mountain Recovery Center, Inc. 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
During an on-site licensure renewal inspection on May 22, 2019, the facility failed to document monthly meetings between employee #2 and their supervisor for the first six months of employment in the clinical supervisor position.
The finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
As per the deficiency stated on May 22, a monthly meeting was held on May 27, 2019 and June 14, 2019 between employee #2 and her supervisor. Going forward Project director will be responsible to ensure that any employee hired will have a monthly meeting with their supervisor for six months upon hire. These meetings will be documented and signed by employee and supervisor. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
During an on-site licensure renewal inspection on May 22, 2019, the facility failed to provide documentation that any staff were instructed in the use of the fire extinguisher upon employment.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
As per citation a fire inspector came to the facility on June 12, 2019 to train current staff on use of fire extinguisher. Going forward all staff members will be trained on use of fire extinguisher upon hire. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
During an on-site licensure renewal inspection on May 22, 2019, the facility did not have any documentation of fire drills occurring in the previous 10 months.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
As per citation on May 22, monthly fire drills were implemented with current staff on May 22, 2019 and June 14, 2019. Clinical director will be responsible for ensuring that monthly fire drills are conducted going forward. Each employee participating in the fire drill will sign a fire drill log indicating participation. Clinical director will check logs on the first Monday of every month to ensure compliance. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
During an on-site licensure renewal inspection on May 22, 2019, the facility did not have any documentation that personnel were trained to perform assigned tasks during emergencies.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
As per citation, A fire inspector came to site on June 12, 2019 to demonstrate use of fire extinguisher including information on the extinguishing of different types of fires. Going forward all employees will be trained on use of fire extinguisher and evacuation plan upon first day of arriving at facility. |