INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 11, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Dreamlife Recovery 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:
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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
Based on a review of the facility fire drill log for the months of May 2024 through August 2024, the facility failed to maintain a written fire drill record including the amount of time it took for evacuation on all reviewed logs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Program Manager will ensure that all of the fire drills include the amount of time it took for evacuation each month. The staff were educated on why this is important and to use the new form that includes all of the necessary items.
This will be audited quarterly by the clinical program manager.
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