INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 13, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Allegiance Rehabilitation Center 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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705.10 (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
Based on a review of fire drills from August 2021 until August 2022, the facility failed to document whether the fire alarm or smoke detectors were operative. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Drill Documentation Form will reflect whether the fire alarm (pull station) or smoke detectors were operative.
The Project Director will sign off on each Fire Drill Document to ensure that the fire alarm or smoke detector was in fact operative. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drills from August 2021 until August 2022, the facility failed to conduct a fire drill during sleeping hours at least every 6 months during the period reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Fire Drill schedule will be scheduled in the facility scheduler so that a fire drill will be conducted during sleeping hours at least every 6 months.
The Project Director will conduct a review of the Fire Drill Schedule every quarter so as to ensure that this corrective action plan is maintained in compliance. |