INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 8, 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, Trehab 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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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The facility failed to maintain the hot water at 120 degrees in the facility's sole client restroom. The hot water was measured at 134 degrees fahrenheit at approximately 10:00am and 12:00pm.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to comply with regulation 705.24 (3) Licensure Bathrooms. The nonresidential facility shall: (3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F ? the following plan of correction has been implemented:
Facility Director contacted the 70 Hollowcrest Road building owner/landlord and indicated there was an issue with the hot water heater maintaining consistent temperature of 120F based on results of the licensing inspection conducted on 2/8/19. Facility Director briefly explained the regulation and the importance of following the regulation for client safety. The building owner/landlord vocalized she would contact the company she uses for building maintenance to adjust the temperature of the hot water heater.
Lead Counselor of 70 Hollowcrest Road outpatient site confirmed with Clinical Supervisor that a certified HVAC/plumbing/maintenance company serviced and adjusted the hot water heater on 3/5/19. Invoice document provided to Clinical Supervisor indicated technician tested water temperature from the faucet located in client bathroom and it never exceeded 113F.
Clinical Supervisor has asked Lead Counselor of the 70 Hollowcrest Road site to monitor the water temperature in the client bathroom weekly for the next 30 days and then monthly by using a digital thermometer (Taylor 9848EFDA Long-Stem, Dual-Scale) purchased by Trehab. Lead Counselor will report any spikes or fluctuations in temperature or other issues observed with the hot water heater directly to the certified HVAC/plumbing/maintenance company for repair, as they have guaranteed their work on the hot water heater (3/5), and to Clinical Supervisor to ensure necessary repairs are completed timely.
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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
The facility failed to conduct fire drills during the months of Feburary 2017 and March 2017. This non-compliance was discovered during the review of the February 2017 through January 2019 fire drill logs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to comply with regulation 705.28. Fire safety. (d) Fire drills. The non-residential facility shall: (6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts ? the following plan of correction will be implemented:
To ensure fire drills meet the expectations of the regulation, Clinical Supervisor has assigned a Fire Drill Coordinator and an Alternate Fire Drill Coordinator at each Trehab outpatient program facility; in the case of 70 Hollowcrest Road site, the Lead Counselor is the coordinator and the Quality Management Coordinator is the alternate coordinator. The coordinator (and alternate coordinator) have been trained about regulation 705.28, the protocol/action steps for completing a fire drill properly (in writing) and has signed a memo indicating understanding of all aspects of the fire drill regulation/protocol.
The coordinator and alternative coordinator have been provided with an updated Fire Drill Log that is specific to the 70 Hollowcrest Road site, that must be used to conduct drills. It entails: 1. The name of the staff person conducting the drill (as assigned by coordinator) 2. The date and time of drill 3. The number or staff members and/or clients present 4. The length of time it took to evacuate the building 5. The exit route used 6. If problems were encountered during evacuation (and who to contact) 7. Indicate if the alarms are operative and which alarm was used/pressed to announce the drill 8. Fire Drill Coordinator signature.
The coordinator and alternative coordinator have been provided with monthly calendar sheets for February ? December 2019. In the upper right hand corner of the sheets is a label that provides the coordinator with a place to indicate who assigned the drill(s) ? coordinator or alternate coordinator, and what shift/time of day the drill will be conducted. The coordinator is responsible for scheduling (at minimum) one (1) monthly, unannounced fire drill at different times of day during staffing shifts. It has been suggested that the coordinator rotate shifts on a monthly basis to cover AM and PM drills, by writing the shift/time of day in the upper right hand corner of the monthly calendar in the (specific) space provided labeled SHIFT. For example, if February's drill was completed during the AM shift, March's drill will be completed during the PM shift. The coordinator for the 70 Hollowcrest Road site also assigns the alarm that will be pressed to announce the drill ? rotating the location to ensure alarms are working properly.
It has been made clear that the goal is to ensure that all staff and clients know how to evacuate the building and to accomplish this, staff-only drills may be conducted at random/different times during the day. It has also been stressed to the coordinator that the schedule of drills is to be kept private and assigned to staff conducting them - on the day of the drill. The coordinator will provide the assigned staff person with the Fire Drill Log ? with appropriate parts filled out, such as which alarm will be pressed to announce fire drill, for example. The coordinator may schedule drills several months ahead using the calendar sheets, but they are not to disclose the drill plan to anyone to safeguard accurate representation of a real fire event. When/if the coordinator is unable to perform these tasks, the alternative coordinator will be asked by the Clinical Supervisor to do so. The coordinator (and alternate coordinator) have been notified that Clinical Supervisor and/or QM Coordinator will randomly inspect Fire Drill Logs and calendar sheets as part of the overall quality management oversight of the physical plant.
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