INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 7, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, McDermott Counseling, 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
|
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
|
Observations
Based on a physical site inspection on January 7, 2022, the facility failed to ventilate the bathroom by exhaust fan or window.
The bathroom did not have a window and the exhaust fan was not working.
These findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Contractor has determined model number of needed exhaust fan at 15 west canal Hershey patient restroom. McDermott Counseling is scheduled for replacement exhaust fan. Contractor estimates repair work within week. estimate service 2/11/2022 |
705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
|
Observations
Based on a physical plant inspection on January 7, 2022, the facility failed to maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor.
The facility failed to have a portable fire extinguisher on the second floor of the facility.
These findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Contacted Kint company to install a second fire extinguisher in 2nd floor office-area not available to anyone but owner of 15 west canal st. property.Kint will install second extinguisher 8a friday February 11 at office address. |
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.
|
Observations
Based on a review of 12 fire drill records, the facility failed to maintain a written fire drill record to include problems encountered at the time of the drill in all records reviewed.
These findings were discussed with facility staff during the licensing process.
|
Plan of Correction
ongoing fire drills will document any problematic occurrences.Agency owner and director is responsible for implementing fire drills /outcomes and possible occurances. Documentation will include when fire drill occurred-who was involved-what area of office. Any situation that deems further action needed to prevent reoccurrance-- will be noted in fire drill log.There will be a designated space/section to outline any noted occurrances during a fire drill |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
|
Observations
Based on a review of 12 fire drill records, the facility failed to conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
The fire drills were always held on a Friday.
These findings were discussed with facility staff during the licensing process.
|
Plan of Correction
ongoing fire drills will not be structured by time/date. drills will be conducted with staggering schedule.Agency owner and director is responsible for implementing fire drill schedule. |