INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 19th, 2018 of Schuylkill Health System Center for Counseling Services by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Schuylkill Health System Center for Counseling Services 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 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure the safety and well-being of clients, staff, and visitors as evidenced by the following:
The rear emergancy exit near conference room C has metal railing that is no longer secured into the cement creating a potiental fall risk as the railing is no longer secure and steady.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Director of Facilities Management at LVHN-S contacted. Contractor completed an on-site assessment and repairs will be completed by July 11,2018.
Responsibility: Program Director
Date of Completion:7/11/18. |
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
A review of the July 2017 to May 2018 fire drill logs was conducted during the onsite inspection. The facility failed to conduct fire drills on different days of the week, at different times of the day and different staffing shifts.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Director of facilities management contacted as his department is responsible for conducting the fire drills.
2.Corrective measures for conducting fire drills with expanded days and times during operating hours identified and communicated. Facilities Management Protocol will be changed to achieve compliance.
Responsibility: Program Director with monthly monitoring to insure compliance.
Time Frame: July 2018 ongoing with monthly monitoring. |