INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on February 20, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Treatment Access and Services Center of Berks County, Inc. (Tasc) 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 drill records, the facility failed to document unannounced fire drills were conducted at least once a month.
The findings include:
On February 20 2013, fire drill records were reviewed for January - December 2012. Per regulation, unannounced fire drills are to be conducted at least once per month. The facility failed to document unannounced fire drills for January - December of 2012.
The intake coordinator was interviewed on February 20, 2013, at approximately 11:00 AM. The intake coordinator confirmed that no documentation was available for unannounced fire drills for 2012.
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Plan of Correction
TASC will conduct unannounced fire drills at least once a month. The Executive Director shall be responsible for scheduling and documentation of these drills. The drills will begin immediately. |
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 manual, the facility failed to maintain a written fire drill record.
The findings include:
Review of the manual presented during the licensing inspection on February 20, 2012, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit 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.
This finding was confirmed by the intake coordinator on February 20, 2013.
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Plan of Correction
TASC will maintain a written record of the monthly fire drills including the date, time, amount of time it took for the evacuation, the exit route used, the number of persons in the facility at the time of the drill, any problems encountered and whether the fire alarm or smoke detector was operative. Documentation will begin immediately and will be the resposibility of the Executive Director. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
A review of the fire drill logs was conducted on February 20, 2013. The fire drills conducted from January-December 2012 were required. Per regulation, a nonresidential facility shall prepare alternate exit routes to be used during fire drills. The facility did not document any alternate exits used during fire drills.
There was no documentation of any fire drills conducted for January-December 2013.
An interview with the intake coordinator was conducted on February 20 2013. It was confirmed that no fire drills were documented to include alternate exits.
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Plan of Correction
TASC has prepared two alternatives for exit, the South stairs and the North stairs. |
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 fire drill record, the facility failed to ensure that fire drills were conducted during different times of the day.
The findings include:
The fire drill record were to be reviewed on February 20, 2013. Twelve months of fire drills were missing. The facility's hours of operation are from 8:00 a.m. until 05:00 p.m. Monday through Friday. The facility failed to document fire drills during the hours of operation.
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Plan of Correction
TASC will conduct monthly unannounced fire drills on different days of the week and different times of the day. TASC has only one shift, 8:00 a.m. to 5:00 p.m. Monday through Friday. |