INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 3 and 4, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Highland House 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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705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on an observation of a routine physical plant inspection, the facility failed to provide a well-secured handrail maintained on the outside stairs. This rail is used for the purpose of an exit for the second and third floor fire escape.
The findings include:
Physical plant inspections were conducted on May 3 and 4, 2011 with the facility director. After an inspection of the wooden handrail on the stairway outside of the half-way house that is used as a fire escape and a conversation with the director, it was confirmed that a portion of the wooden handrail was rotted and had broken away from the remainder of the handrail. The deteriorated condition of the handrail presented a potential safety issue for individuals who would need to exit the building via the staircase.
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Plan of Correction
The Executive Director contacted a contractor May 12, 2011 to examine the entire fire escape and repair any and all rotted wood. The contractor reviewed the work needing completed and ordered the wood and paint to repair the escape.
The repair will be completed by the 5th of June. The executive director will follow-up on June 6, to assure that the work has been completed. |
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 the fire drill record log, the facility failed to document one monthly fire drill.
The findings include:
The fire drill record log was reviewed on May 4 th, 2011. The log was reviewed from May 2010 to April 2011. One of those twelve months did not have documentation that a fire drill was conducted. A fire drill was not conducted during the month October 2010. A conversation with the director on May 5th, 2011, confirmed the fire drill in October 2010 had not been conducted.
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Plan of Correction
The staff member was written up for failure to complete the drill she was scheduled. The House Manager will schedule all emergency drills during the month on different shifts.
The House Manager and executive director will check the fire drill log in the middle and toward end of each month to assure that the drill has been completed. |