INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on Octoebr 16, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Children's Service Center of Wyoming Valley 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 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The fire extinguisher by the kitchen area was not inspected in the last year. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Children's Service Center of Wyoming Valley as of 10/16/24 replaced the expired fire extinguished with one that has been inspected annually by a fire extinguisher company. The Children's Service Center will ensure annual fire extinguisher inspection occurs. It will be the responsibly of the facility maintenance department to ensure annual inspection. It will be the responsibility of the Clinical Supervisor and Facility Director to monitor appropriate inspection. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the October 2023 through October 2024 fire drill logs during the inspection, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Children's Service Center of Wyoming Valley has submitted an exception request for 705.28 (d)(7) relating to setting off a fire alarm or smoke detector during each fire drill. The fire alarm is hardwired and sets off for the building as a whole as this is a rental space with other tenants occupying the building. If approved, the facility will continue to conduct fire drills per policy for staff members and patients by notifying them via alternative noise. It will be the responsibility of the Clinical Supervisor and Facility Director to follow through with policy and exception request. |