INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 2, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Licensure Programs. Based on the findings of the on-site inspection, The Retreat at White Birch 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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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 fire drill logs from August 2020 through May 2021, the facility failed to document whether the fire alarm or smoke detector was operative on each log.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Our facility failed to document whether the fire alarm or smoke detector was operative during fire drills.
To correct this deficiency, the fire drill log was updated to include documentation for reporting whether the fire alarm/smoke detector system is working properly or if there was a problem.
To prevent re-occurrence of this deficiency, the Executive Director or the Quality Control Coordinator will document whether there was a problem with the fire alarm/smoke detector system or whether the system was working properly during monthly fire drills.
An updated copy of the revised Fire Drill Log will be forwarded to the DDAP |