INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 16, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County 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) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in one of two applicable records reviewed.
Staff #2 was hired on April 3, 2023 and still a current employee has not been trained on the use of fire extinguishers as of the date of onsite inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the orientation process with the human resource department, new staff will complete the fire extinguisher training on first day of employment and it will be documented in the employee's record. Facility Director will follow up confirming the fire extinguisher training has been completed.
Staff #2 who is still a current employee has completed the fire extinguisher training conducted by the human resource department director and it has been documented in employee's record. The date completed is reflected in the Corrective Action Date. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in one of two applicable records reviewed.
Staff #2 was hired on April 3, 2023 and still a current employee has not been trained to perform assigned tasks during emergencies as of the date of onsite inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the orientation process with the human resource department, new staff will be trained to perform all tasks during emergencies on the new employee's first day of employment. The completed training will be documented in the employee's record. Facility Director will follow up confirming assigned tasks emergency training has been completed.
Staff #2 who is still a current employee has has been trained to perform assigned tasks during emergencies by the human resource department director and it has been documented in employee's record. The date completed is reflected in the Corrective Action Date. |
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 review of fire drill logs, the facility failed to maintain a written fire drill record to include problems encountered.
Reviewed fire drill records from January 2023 through October 2023. Written fire drill log did not include problems encountered during any fire drills from January to October 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The office coordinator will 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. The facility director will check monthly for accuracy of the log being kept.
The officer coordinator if any issues are found will conduct a new fire drill prior to the end of the month and log the new fire drill. |
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.
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Observations
Based on a review of fire drill logs, the facility failed to set off a fire alarm or smoke detector during each fire drill.
Reviewed fire drill records from January 2023 through October 2023. Verification of fire drill logs does not indicate that a fire alarm or smoke detector was set of for the months of January to October 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The office coordinator will keep an accurate log of the fire alarm and smoke detector during each drill was set off through verification of accurately kept fire drill logs. The facility director will confirm the accuracy of the fire drill log on a monthly basis.
The office coordinator if any issues are found will conduct a new fire drill prior to the end of the month. The new drill will be documented in the fire drill logs. |