INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 13, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, A-Spot 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 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical site inspection, it was determined that the facility failed to ensure fire extinguishers were mounted to the wall.
The fire extinguisher located near the kitchen was not mounted to the wall.
This finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Response to Licensing Inspection Deficiency: Fire Safety Compliance with 705.28 (c)(1)
Policy Statement:
The nonresidential facility shall maintain a portable fire extinguisher with a minimum of an ABC rating on each floor. If there is more than 2,000 square feet of floor space on a floor, an additional fire extinguisher will be provided for every 2,000 square feet or fraction thereof. Fire extinguishers must be securely mounted to the wall to ensure proper accessibility and safety.
Response and Plan of Correction:
Immediate Action:
The fire extinguisher located near the kitchen has been mounted to the wall in compliance with the regulation, using an appropriate mounting bracket that ensures it is securely affixed at the proper height and location for accessibility.
A full inspection of all fire extinguishers in the facility was conducted, and any extinguishers not properly mounted were immediately corrected.
Preventive Measures:
A annual facility safety inspection checklist has been implemented to ensure that all fire extinguishers are properly mounted, accessible, and compliant with the ABC rating requirement.
Ongoing Monitoring:
The facility will incorporate fire extinguisher placement and mounting checks into the routine licensing preparation process.
The Program Director or their designee will oversee annual safety inspections.
Completion Date:
Immediate corrective actions, including the mounting of the kitchen fire extinguisher and the inspection of all extinguishers, were completed on 12/14/2024.
Preventive measures, including the implementation of the safety inspection checklist, were fully implemented as of 12/14/2024.
The facility is committed to maintaining compliance with fire safety regulations and ensuring the safety of all staff, clients, and visitors.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs the facility failed to conduct unannounced fire drills at least once a month. At the time of the inspection, there was no documentation of any completed fire drills.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Response to Licensing Inspection Deficiency: Fire Safety Compliance with 705.28 (d)(1)
Policy Statement:
The nonresidential facility is committed to conducting unannounced fire drills at least once a month. Comprehensive documentation, including all required elements?date, time, duration, exit route used, number of individuals present, problems encountered, and whether the fire alarm or smoke detector was operative?will be maintained to ensure compliance with regulatory standards and readiness in the event of an emergency.
Response and Plan of Correction:
Immediate Action:
A fire drill was conducted on 12/14/2024 at 10:00 AM to address the identified deficiency. The details of the drill are as follows:
Date: 12/14/2024
Time: 10:00 AM
Evacuation Duration: Approximately 1 minute
Exit Route Used: Front of the building exit
Number of Residents Present: 0
Number of Staff Present: 1
Alarm Activation: Yes, the fire alarm was operative and operational
Issues Encountered: None
Documentation of this drill has been completed and filed using the standardized fire drill record form provided by DDAP. This ensures all required elements are properly documented.
Development of Fire Drill Log System:
A comprehensive fire drill log system has been established to ensure accurate and consistent documentation moving forward. The log includes the following fields:
Date of the drill
Time of the drill
Evacuation duration
Exit route used
Number of persons present (both residents and staff)
Whether the fire alarm or smoke detector was operative
Any problems encountered during the drill and corrective actions taken
Preventive Measures:
Fire Drill Schedule:
A fire drill schedule has been implemented to ensure unannounced drills are conducted monthly. While the drills remain unannounced to staff and clients, designated personnel will follow the schedule to ensure compliance.
Ongoing Monitoring:
Fire drill logs will be reviewed monthly by the Program Director or their designee to ensure all required elements are documented and to address any gaps promptly.
Logs will be securely maintained and readily available for inspection during future licensing visits.
Completion Date:
Immediate corrective actions, including the unannounced fire drill on 12/14/2024, have been completed.
Preventive measures, including the implementation of the fire drill log system and schedule, have been fully operational as of 12/14/2024.
Commitment to Compliance:
The facility remains dedicated to full compliance with 705.28 (d)(1), prioritizing the safety of staff, clients, and visitors by ensuring effective emergency preparedness and thorough documentation of fire drills.
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