INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 5, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Human Services Administration Organization 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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705.28 (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 March 2020 through January 2021 fire drill records, the facility failed to document monthly fire drills were conducted from March 2020 through August 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Drills will be conducted monthly unless otherwise indicated by DDAP.
Compliance with this expectation will be monitored by the Project Director and/or the Facility Director.
Facility will be in full compliance with these standards as of 3/17/21.' |