INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 28, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, DLP Conemaugh Memorial Medical Center 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 document a fire drill log which included the exit route used.
The fire drills logs for May 2018 to December 2019 were reviewed on January 28, 2020. The fire drill logs did not document the exit route used during the fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Manager has updated the fire drill log to now include a route of exit for each fire drill that takes place.
Fire exits have been identified as exit A or B, as they had been in the past. This modification has been added to the fire drill form as of 2/4/20, allowing New Visions to be in compliance with the necessary documentation required for fire drills.
The Program Manager will document all fire drills on a monthly basis, and in his/her absence, the Program Secretary will document all necessary fire drill information. Fire drills are documented in a fire drill log, which is stored in the Program Managers office. |