INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 21, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Engagement, 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) (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
Based on a review of documentation submitted for fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.These findings were reviewed with the facility during the licensing process.
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Plan of Correction
At minimum, monthly fire drills will be conducted, no matter the state of the agency being open or not. This procedure will be over seen by the Facility / Project Director to make sure it occurs at least on a monthly basis. |