INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 3, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Ellen O'Brien Gaiser Addiction Center 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 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs, the facility failed to maintain a written fire drill record to include the amount of time it took for evacuation and the time of day in which the fire drill was conducted.
The findings include:
Fire drill logs were reviewed on June 3, 2015. Fire drill documentation was reviewed from August 2014 through May 2015. The facility failed to include on the August 2014 fire drill the amount of time it took for evacuation and on the November 2014 fire drill the facility failed to document the time of day.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director met with the Facility Manager on June 29, 2015 and instructed her to record the amount of time it takes to evacuate the building and the time of day that each fire drill occurs on the documentation log for each facility fire drill. This will be monitored by the Executive Director through monthly supervision of Facility Manager. |