INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 8, 2026 staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Antioch Recovery Services Llc 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:
|
Plan of Correction
|
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.
|
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 in the hallway was last inspected September, 2024.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility has scheduled an inspection with a licensed fire extinguisher service company to conduct a full inspection and approval of all fire extinguishers. Any extinguisher found to be inoperable will be repaired or replaced within 48 hours, in compliance with regulation.
Responsible Person:
Project Director
Action Plan
The facility has implemented a Fire Safety Inspection Log to track annual fire extinguisher inspections.
Annual inspection reminders have been added to the facility's compliance calendar.
The Project Director will conduct quarterly visual checks to ensure inspection tags are current and visible.
Completion Date:
02/05/2026
Status:
Corrected / In Compliance |
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.
|
Observations
Based on a review of the January, 2025 through December, 2025 fire drill logs during the inspection, the facility failed to set off the fire alarm or smoke director during each fire drill. The Project Director did confirm that neither the smoke detector nor fire alarm was set off during each fire drill.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
I have submitted a request for the waiver for alternate means of announcing a fire drill.
Effective immediately, the Project Director will conduct fire drills using approved alternative notification methods due to the facility being located in a shared commercial business building where activation of the central fire alarm system is prohibited by the property owner and building management. ecause the fire alarm system serves multiple tenants and cannot be activated for drills, the facility will implement the following functionally equivalent emergency notification process:
Use of a verbal emergency announcement ("This is a fire drill?initiate evacuation procedures"). Use of portable audible devices, which will be a handheld device to simulate alarm activation. Staff initiation of immediate evacuation protocols, including: Staff escort of clients
Identification of primary and secondary exits
Assembly at designated evacuation point
Completion of evacuation within documented timeframes.
|