INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on March 6, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pathway Services, LLC 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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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observation during the licensing inspection and a conversation with the Project Director, the facility failed to ensure that there were no portable heaters within the facility.The findings include:The licensing specialist conducted the inspection in the chiropractor's office.The Project Director offered the licensing specialist a portable space heater that was not permanently mounted or installed.The licensing specialist declined the offer and informed the Project Director that portable space heaters are not allowed within the facility.
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Plan of Correction
On the day following the licensing inspection The Project Director removed the portable heater from the facility. A memo went out from the owner to the project director and the certified addictions counselor at Pathway Services, LLC banning the use of portable heaters within the facility, as of 3/07/2012. The steps the facility will take to ensure this deficiency does not recur are as follows. The anual building inspection report will address the issue of not having any portable heaters on the property at any time. The person responsible for ensuring this corrective action is implemented is the properity manager. His anual report will be placed in the fire drill folder. |
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 fire drill log, the facility failed to set off a fire alarm or smoke detector during each drill.The findings include:On March 6, 2012 the facility's fire drill log and administrative documentation were reviewed.The facility did not set off a fire alarm or smoke detector during twelve of twelve fire drills.The facility has an exception to the Department of Health's Physical Plant Standard for Nonresidential Facility's, Chapter 705.28 (d)(7), relative to activation a fire alarm or smoke detector during a fire drill.However, the facility failed to provide documentation that the fire alarms/smoke detectors are in working order.The owner confirmed the findings.
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Plan of Correction
At the time of inspection on 3/06/12 both the licensure inspector and the owner were unable to locate the documentation that the fire alarms/smoke detectors are in working order. On March 9, 2012 The facility corrected the deficiency by finding the documentation dated Feburay 18, 2012. The document stated that in reguards to building safety, "All of the smoke detectors on both floors were tested on February 15, 2012. They were found to be in good working order." This documentation is signed and dated by the Project Director. The owner put this document in the fire-drill folder at the facility. The steps the facility will take to ensure that this deficiency does not recur are as follows: The annual building inspection will include making sure that all smoke detectors are in good working order. The person responsible for the annual inspection is the building manager. The smoke detectors at Pathway Services, LLC are battery operated. The building manager is responsible for changing any batteries as needed and for replacing any non-working smoke detectors immediately. Prior to the annual state licensure inspection, the owner will review the fire drill folder to make sure all necessary documantaion is up to date and placed in the file. |