INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 14, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Twin Lakes Center, Inc. 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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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on observation during a physical plant inspection, the facility failed to ventilate the bathroom by exhaust fan or window.
The findings include:
A physical plant inspection was conducted with the clinical supervisor on August 14, 2015 at approximately 8:30 AM. The facility has one unisex bathroom for staff and clients. This restroom did not have an exhaust fan or window. The facility failed to ventilate the bathroom by exhaust fan or window.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Outpatient Supervisor had talked to the landlord regarding the exhaust fan and one was installed in the bathroom on August 31st 2015. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure the front exit of the facility was unobstructed.
The findings include:
A physical plant inspection was conducted with the clinical supervisor on August 14, 2015 at approximately 8:30 AM. The front entrance of the facility consists of two individual glass doors that have double-keyed deadbolt locks. The front entrance is a posted emergency exit. These double-keyed deadbolt locks would prevent the front exit from being operable at all times. The facility failed to ensure the front emergency exit of the facility was unobstructed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Outpatient Supervisor will work with the landlord to replace the locks on the door so that it will be operable at all times by 10/31/15. |