INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 24, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Public Health Management Corporation d/b/a Chances 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 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential 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, the facility failed to ensure all fire extinguishers were inspected and approved annually by the local fire department or a fire extinguisher company.
At the time of the inspection, there was one fire extinguisher, located in the staff common cubicle area, that was last inspected in July 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and supervisors responsible for ensuring facility fire extinguisher upkeep will be trained by the Program Director on the 705.28 (c) (3) LICENSURE fire safety requirement and on this Plan of Correction by 10/31/2025. The training will include that the nonresidential facility shall 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. Training will be completed by 10/31/2025. A copy of the training completion and staff participating will be kept on file in the staff members' training files.
Issues identified by the DDAP inspection were addressed as follows: on 9/24/25, the Program Director notified the fire extinguisher company of the expired inspection date on the fire extinguisher, located in the staff common cubicle area, that was last inspected in July 2024. The fire extinguisher company inspected and approved and tagged the fire extinguisher on 9/26/25.
During regular (e.g. monthly) facility checks, The Program Director or Program Director's designee will review that fire extinguishers are kept according to 705.28 (c) (3) fire safety regulatory requirements. The Program Director's Designee will report any issues to the Program Director for internal Plan of Correction, who will create and send any correction issues to the fire extinguisher company or PHMC facilities department by email or phone when appropriate. Copy of any facilities ticket requests and a copies of the completion reports will be kept on file in the PHMC facilities database.
This plan of correction will be fully implemented by 10/31/2025.
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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 facility's September 2024 through August 2025 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
At the time of the inspection, there was no documentation indicating fire drills had been conducted during each month from February 2025 through August 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and supervisors responsible for ensuring facility fire drills will be trained by the Program Director on the 705.28 (d) (1) LICENSURE Fire Safety requirement and on this Plan of Correction by 10/31/2025. The training will include that the nonresidential facility shall conduct unannounced fire drills at least once a month. Training will be completed by 10/31/2025. A copy of the training completion and staff participating will be kept on file in the staff members training files.
Issues identified by the DDAP inspection were addressed as follows: on 9/25/25, the Program Director created a yearly schedule for the at-least-monthly unannounced fire drills.
During regular (e.g. monthly) facility checks, The Program Director or Program Director's designee will conduct and document the unannounced fire drills according to 705.28 (d) (1) fire safety regulatory requirements. The Program Director's Designee will report any issues to the Program Director for internal Plan of Correction. Documentation of conducted fire drills will be kept on file in the Program Director's office for review .
This plan of correction will be fully implemented by 10/31/2025.
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