INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 30, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Phillhaven 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) (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 drills from October 2023 through April 2024, the facility failed to conduct unannounced fire drills at least once a month.
The October 2023 fire drill identified that training staff will be notified in the morning of upcoming fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Effective 6/17/24, updated Fire Safety Policy to include all required elements in 705.28
- Effective 6/17/24. updated Fire Drill Reporting form to include a checkbox to confirm the drill was unannounced.
- Facility Director or designee will provide education on requirements to those responsible for completion of fire drills by 6/21/24. Those staff who are responsible for the completion of fire drills who may on PTO, FMLA or extended leave will be educated to requirements upon their return. |
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 the review of the facility's fire drill log for the months of October 2023 through April 2024, the facility failed to document the exits used during the fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Effective 6/17/24, updated Fire Safety Policy to include all required elements in 705.28
- Effective 6/17/24 updated Fire Drill Reporting form to include details of exits used
- Facility Director or designee will provide education on requirements to those responsible for completion of fire drills by 6/21/24. Those staff who are responsible for the completion of fire drills who may on PTO, FMLA or extended leave will be educated to requirements upon their return. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the facility's fire drill log for the months of October 2023 through April 2024, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts. The months of November, December, March, and April fire drills were all conducted on the same day. The months of November, December, January, February, and March fire drills were all between the hour of 2:30 pm and 3:30 pm.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Effective 6/17/24, updated Fire Safety Policy to include all required elements in 705.28
- Effective with fire drills beginning July 2024, the Facility Director or designee will ensure drills are conducted during various days, times and shifts
- Facility Director or designee will provide education on requirements to those staff responsible for completion of fire drills by 6/24/24. Those staff who are responsible for the completion of fire drills who may on PTO, FMLA or extended leave will be educated to requirements upon their return.
- Facility Director or designee will complete monthly Fire Drill audits to monitor compliance. Audit results will be reported monthly to the Quality Management Council by the Facility Director or designee until success is achieved. The rate of success will be defined by evidence of 3 consecutive months of 100% compliance. |