INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 15, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, High Focus Centers 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
Based on a review of the facility's February 2024 through December 2024 fire drill logs, the facility failed to ensure their written fire drill logs included the amount of time it took for an evacuation.
The fire drill logs for the months of July 2024, August 2024, and September 2024 did not include documentation of the amount of time it took for each fire drill evacuation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Office Administrative Assistant (OAA) and the Executive Director (ED) met on 1/16/25 to identify a process for recording and filing fire drill details manually and electronically moving forward. This process will ensure that all data from the drills, including the time it takes for each fire drill evacuation, are collected and filed. The OAA will monitor the fire drills monthly and report any issues to the ED. The OAA will maintain the handwritten fire drill records on site. |