This report is a result of an on-site licensure renewal inspection conducted on January 11, 2010 through January 14, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Service Foundation, 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 and a plan of correction is due on February 10, 2010.
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Plan of Correction
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Observations
Based on a physical plant inspection on January 14, 2010, the facility failed to ensure there are two exits on every floor, including the basement, that are at least fifteen feet apart.
The findings include:
A physical plant inspection was conducted on January 14, 2010 at approximately 1:00 PM. During an inspection of each floor, it was found that the facility has a split basement. Half of the basement is separate from the other half. One half of the basement has two exits. The second half of the basement, inaccessible to the other half of the basement, has only one exit.
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Plan of Correction
As of 2/9/2010, drug and alcohol counseling activities will not be conducted in the half basement area which does not have the appropriate two means of egress. The executive director and the assistant director of drug and alcohol programs will ensure this area to be off limits to drug and alcohol counseling. All drug and alcohol counseling activities will be conducted in approved areas. |