INITIAL COMMENTS
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This report is a result of an initial on-site physical plant inspection. The inspection was conducted December 13, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the physical plant inspection, Positive Pathways was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility, specifically 28 Pa. Code Subsection 705.1.
Since this was an initial physical plant inspection, not all regulations were reviewed. During future inspections, all regulations will be reviewed for compliance.
The following deficiencies were identified:
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Plan of Correction
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
A physical plant inspection was conducted on December 13, 2016. The facility failed to ensure privacy so that counseling sessions could not be seen or heard outside the counseling room as the room identified as a waiting area / group room was accessed by the main door. This door had windows without frosting and/or blinds which could allowed individuals to look in and see group members.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
A physical plant inspection was conducted on December 13, 2016. The facility failed to ensure that all stairways, hallways and exits from rooms and from the nonresidential facility were unobstructed as the exit door from the counseling office had a lock on the reverse side of the door, that if locked, would prevent people in the facility from existing.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (a) (1) (iv) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
A physical plant inspection was conducted on December 13, 2016. The facility failed to clearly indicate exits by the use of signs as the exit from the counseling office was not marked with an exit sign.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |