INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensure inspection that was conducted on December 27, 2010 through December 28, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from the on-site inspection, SOAR Corp. 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 supervisory review and a plan of correction is due on April 4, 2011.
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Plan of Correction
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record log and an interview with the clinical supervisor, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
The fire drill record log was reviewed on December 27, 2010. The log was reviewed for the period covering January 2010 to December 2010. There was no documentation that a fire drill was conducted during May 2010.
During an interview with the clinical supervisor, the lack of documentation was confirmed.
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Plan of Correction
On 01/12/2011, the Health and saftey team met with the Director for training on fire saftey, drills and doucmentation. The facility will conduct unannounced fire drills at least once a month and document it in the fire drill log book. The Director will montior monthly to ensure this defiency does not recur. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the fire drill record log and an interview with the clinical supervisor, the facility failed to conduct unannounced fire drills at different times of the day and on different
staffing shifts during seven of the eleven months of which the fire drills were conducted.
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The findings include:
The fire drill record log was reviewed on December 27, 2010. The log was reviewed for the period covering January 2010 to December 2010. There was no documentation that a fire drill was conducted during May 2010. The fire drills for January, April, June, July, August, September, and October were conducted at either 2:00 PM or 2:30 PM.
Drills were conducted on:
January 14, 2010 at 2 PM
April 29, 2010 at 2:30 PM
June 28, 2010 at 2:30 PM
July 26, 2010 at 2:30 PM
August 25, 2010 at 2 PM
September 24, 2010 at 2 PM
October 29, 2010 at 2:30 PM
During an interview with the facility director, the fire drill times were confirmed.
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Plan of Correction
On 01/12/2011, the Health and Saftey team met with the director for training on fire drill procedures.The facility will conduct fire drills on different days of the week, at different times of the day and on different staffing shifts. The director will monitor monthly to ensure this defiency does not recur. |