INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 15, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Positive Pathways 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
The facility failed to maintain a fire drill record that documented the exit route used, the number of persons in the facility and problems encountered for the January 2017 - April 2017 fire drills reviewed during the annual licensing inspection conducted on May 15, 2017.
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Plan of Correction
Plan of Correction:
Plan of Correction: The facility's fire drill log was updated to include which exit route was used, the number of persons in the facility and problems encountered, if any, during the fire drill process.
Timeframe to Completion: Completed
Methodology for Achieving and Maintaining Compliance: Project Director will utilize the updated fire drill log in each monthly fire drill.
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