INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 28, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Program for Offenders, Inc. 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 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection conducted on May 28, 2014, the facility failed to ensure that exits from the nonresidential facility were unobstructed and operable at all times.
The findings include:
A physical plant inspection was conducted with the facility director on May 28, 2014 at approximately 9:45 AM. The glass door to the lobby of the building was observed to have a double keyed deadbolt lock. This glass door is posted as an emergency exit. The double keyed deadbolt lock would prevent this exit door from being operable at all times. The facility failed to ensure that exits from the nonresidential facility were unobstructed and operable at all times.
The facility director was interviewed throughout the licensing inspection and confirmed there was a double keyed deadbolt on this exit door.
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Plan of Correction
THE PROGRAM will ensure that all emergency exits are unobstructed and operable at all times. The Facility Director will work with Building Management to correct the issue. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill records for July 2013 through May 2014 were reviewed on May 28, 2014. The facility utilized the same exit route for each fire drill conducted from July 2013 through May 2014. This route was the exit directly across from the entrance to the facility's office suite. The facility failed to prepare alternate exit routes to be used during fire drills.
The findings were not disputed by the facility director.
This is a repeat citation from the June 27, 2013 licensing inspection.
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Plan of Correction
Fire Drills will utilize alternate exits to prepare for all emergency situations. Facility Director will review monthly fire drill logs to ensure compliance. |