INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 2, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Just Believe Recovery Center at Mountain's Edge, 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:
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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 site inspection on November 2, 2021, the facility failed to ensure fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
Both fire extinguishers had expired tags on them dated August 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately following this inspection, the fire extinguisher company, Mander, was contacted. On 11/24/2021 the fire extinguisher company came to inspect each extinguisher. All tags are now up-to-date as listed for November 2021. |
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 request for the facility ' s fire drill records, from February 2021 to present, the facility reported they had not conducted any unannounced fire drills during that time period.
These findings were discussed with the facility during the licensing process.
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Plan of Correction
Following this inspection, clinical director and director of operations met to discuss and implement fire drills at the facility. On 11/30/2021 a fire drill was conducted at the facility. Fire drills will continue to be conducted monthly during hours of operation. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 request for the facility ' s written fire drill record, the facility reported that the facility did not have a written fire drill record.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
Following this inspection, clinical director and director of operations met to discuss fire safety drills and logs. On 11/30/2021 a fire drill was conducted at the facility and a written fire drill log was filed. |