INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 13, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Care Center d/b/a SPHS Care Center 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) (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
The facility failed to maintain a written fire drill record that included the amount of time it took for evacuation for the fire drill logs reviewed on February 13, 2018.Fire drill logs for the time period of July 2017 to January 2018 were reviewed. The fire drill logs did not document the amount of time it took for evacuation. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisor will be responsible for documenting the duration of time in minutes for all staff involved in evacuation on the fire drill log after every conducted fire drill. The Clinical Director will be responsible for ensuring that the procedure was followed through adequately. This correction was implemented on 2/19/2018. |