INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 5, 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, Harwood House was found to not 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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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential 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
During an onsite inspection on February 5, 2019, it was found that the facility failed to ensure that all fire extinguishers are inspected and approved by the local fire department or fire extinguisher company annually.
The fire extinguisher in the back kitchen had not been inspected or approved by the local fire department or fire extinguisher company.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff on duty the day the fire extinguishers are inspected and approved by the company is responsible for checking that all fire extinguishers are tagged and dated as checked.
The staff responsible for completing monthly safety checks of the house is responsible for checking that all fire extinguishers are properly tagged. If the tag is not present, this person will contact the company for a check of the extinguisher.
The program director is responsible for overall compliance.
The fire extinguisher was checked and tagged by the company on 2/6/2019. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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
During review of the fire drill record on February 5, 2019, it was found that the facility failed to document whether the fire alarm or smoke detector was operative.
There was no documentation of whether the fire alarm or smoke detector was operative on the fire drills from January 2018 through January 2019.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The staff on duty is responsible for proper documentation of the fire drill.
The Clinical Supervisor is responsible for ensuring that documentation is completed.
The Program Director is responsible for overall compliance.
The fire drill form was updated to include a line stating that smoke detector and fire alarms were operative at the time of the drill. yes or no.
The new form was placed in the staff log for all employees to view.
The form will be presented and discussed at the clinical meeting on 2/11/19 and at the program worker staff meeting on 2/18/19. |
705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
During a review of the fire drill records on February 5, 2019, the facility failed to conduct fire drills on different days of the week.
The fire drill record documented six out eleven fire drills were conducted on Thursdays from January 2018 through January 2019.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The staff on duty is responsible for conducting a fire drill monthly and documenting the drill on the fire drill form.
The clinical supervisor is responsible conducting fire drills on different days of the week.
The executive director is responsible for overall compliance.
The program director met with the clinical supervisor on 2/6/19 and discussed the scheduling of fire drills to be on varied days. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
During a review of the fire drill records on February 5, 2019, the facility failed to document that they set off a fire alarm or smoke detector during each fire drill.
The fire drill records from January 2018 through January 2019 did not document which fire alarm or smoke detector was set off during each drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the staff person on duty to document the fire drill properly.
It is the responsibility of the clinical supervisor to ensure that fire drills are documented properly.
the program director is responsible for the overall compliance.
The facility is requesting an exception of this regulation, setting off the alarm will not show which detector sounded. Harwood will Central Systems and report we are conducting a fire drill. Staff on duty will sound alarm to verify that the system works properly. |