INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 11-12, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Abuse Services, Inc 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
|
705.28 (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 the facilities records submitted as part of the presubmission process the facility failed to document all of the required information in its fire drill records.
There was no time documented for the fire drill conducted on October 5, 2016.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
The clerical supervisor on 9/12/17 sent an email to all staff who do fire drills advising them of the importance of putting the time in. Additionally the form was revised to include am and pm.
The clerical supervisor will review all forms for accuracy monthly. The facility director will review all forms quarterly to ensure accuracy and that the time is documented. |