INITIAL COMMENTS
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This report is a result of an initial on-site physical plant inspection preceding a facility activity relocation. The inspection was conducted on July 3, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the physical plant inspection, Retreat of Lancaster County 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.
Since this was a physical plant inspection preceding a facility relocation, not all regulations were reviewed. During future inspections, all regulations will be reviewed for compliance.
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Plan of Correction
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705.28 (b) (2) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(2) Place the smoke detector in a common area or hallway. All detection devices shall be interconnected.
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Observations
Based on a physical plant tour, the facility failed to provide a smoke detector within the building.
The findings include:
A physical plant tour was conducted with the director. The facility did not have a smoke detector at the front of the building in a common area.
The director confirmed the findings.
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Plan of Correction
Smoke detector has been installed in the front of the building and this was verified with Executive Director. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant tour, the facility failed to provide inspected fire extinguishers within the building.
The findings include:
A physical plant tour was conducted with the director. The facility had a fire extinguisher that had not been inspected since May 2010 at the front of the building.
The director confirmed the findings.
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Plan of Correction
Fire Extinguisher has been currently inspected and is up to date. Executive Director has verified this. |