Observations
Based on a review of the facility's August 2025 through October 2025 fire drill log, the facility failed to ensure that unannounced fire drills were conducted at least once a month.
At the time of the inspection, there was no completed fire drill documented during the month of September 2025 in the facility's fire drill logs.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A new receptionist was hired at Quakertown location, along with several other staff members as the location is growing. The receptionist will now be completing fire drills monthly, throughout different shifts, as she is at the site each day. She has completed the last two month and will continue to ensure proper fire safety. Each month, the fire drills are uploaded into shared agency file and monitored by Director of Quality Assurance to ensure they are complete. |