INITIAL COMMENTS
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This report is a result of an initial on-site licensure inspection conducted on February 12, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago-Pottsville 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 and a plan of correction is due on March 12, 2009.
Since this was the initial inspection conducted, 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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705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on the physical plant inspection, the facility failed to ensure two exits separated by a minimum of 15 feet.
The findings include:
A physical plant walk through was conducted on February 12, 2009 at approximately 11:00 AM. Room #6, which had four beds, contained two exits that were less than 15 feet apart.
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Plan of Correction
The facility will not use bedroom # 6 until the cited issue has been resolved
The facility is requesting approval for 12 beds instead of 16 as a result of the recent inspection.
Moving foward, modification will be made to bedroom # 6 by cutting a doorway through a common area to connect the 3rd floor areas thus creating another exit for bedroom # 6. The date for such modification has not been set.
The Facility will notify the department upon completion of the doorway and will request an increase to 16 beds at that time.
Upon completion of the doorway we will request an additional site visit to verify its completion.
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