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 July 13, 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, MVP Recovery, LLC 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 a review of the November 2019 through June 2020 fire drill log, the facility failed to identify on the fire drill log which exit route was used and whether the fire alarm or a smoke detector was operative during each fire drill conducted.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MVP Recovery has added the following sections to our Fire Drill Log: 1)Which exit route was used; 2)Whether a fire alarm or smoke detector was operative during each fire drill conducted.
Continued monitoring of fire drills will be conducted by Executive Director and/or authorized designee.
This corrective action has taken place as of the July 14, 2020 Fire Drill. |
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 a review of the November 2019 through June 2020 fire drill log, the facility failed to set off the fire alarm or a smoke detector during each fire drill conducted.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
MVP Recovery will have the Executive Director and/or authorized designee set off the fire drill alarm and/or smoke detector for each fire drill conducted. This action will be added to the Fire Drill log to ensure compliance for each drill conducted.
This was completed for the Fire Drill conducted on 7/14/2020 and will continue moving forward. |