INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 11 - 12, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Twin Lakes Center 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 (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
The facility failed to ensure all exits from the non-residential facility were unobstructed based on a physical plant inspection conducted on April 11, 2019 at approximately 9:30 AM.
The entrance door to the facility's suite had a double keyed deadbolt lock. Also, the main entrance to the building had a double keyed deadbolt lock on the second set of glass doors. These doors were posted as emergency exits and the locks would prevent the exits from being operable at all times.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The MSH supervisor will ensure that Facilities Management has updated the lock on the outside of the facility by 5/31/19 to ensure it is an emergency exit at all times. The MSH supervisor added a new lock to the facility door on 4/19/19 that will allow the door to be an emergency exit at all times. |
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
The facility failed to set off a smoke detector or fire alarm during each fire drill based on a review of the July 2018 - March 2019 fire drill records on April 11, 2019.
A smoke detector or fire alarm was not set off for the following drills: July 2018, August 2018 and October 2018 through March 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Maintenance supervisor installed a fire alarm in the facility's reception area on April 11, 2019. Each fire drill completed after that date will have the alarm set off during the drill. The Director of Outpatient and the Maintenance Supervisor will ensure that they are setting off the alarm each time by reviewing the paperwork submitted. |