INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 24-25, 2016, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Main Line Affiliates d/b/a Mirmont Outpatient Services 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) (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
The facility failed to document all of the required information on the fire drill logs for the facility.
The fire drill log for the fire drill conducted on 12/31/2015, did not document the exits used during the fire drill.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Designate an item line on the fire drill log to indicate the Exits Used and Exits Blocked. Completed on 11/14/2016
Responsible Party: Site Manager
Instituted controls:
1.Two staff members to sign off on the plan once the Safety Coach turns in the report from the fire drill. This is an addition to the previous one person sign off.
2. Monthly fire drills will be conducted on site
3. Site Manager or Director will ensure that this is completed on a monthly basis.
Completed by 11/21/2016 for next fire drill exercise
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