INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 28-29, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Guidance 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
Based on a review of facility documents submitted as part of the presubmission process the facility failed to include all of the required information in its fire drill records.
The fire drill log for the fire drill conducted on 03/21/2017, does not document the evacuation route used in the fire drill.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
A formal retraining of safety committee members assigned to conduct routine fire drills occurred on September 11, 2017 to include the thorough completion of fire drill documentation. The Assistant Director will routinely monitor monthly fire drill submissions to ensure all information is accurate and completed fully. |
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 facility documents submitted as part of the presubmission process, and based on staff interviews conducted during the onsite inspection, the facility failed to use alternate evacuation routes for its fire drills.
The facility used the front door exit for every fire drill from 09/20/2016, though the onsite inspection.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Based on licensing feedback, the Center has retrained designated members of the Center Safety Committee that are responsible for executing monthly unannounced fire drills. Beginning in September 2017, the Center has implemented protocol that monthly unannounced fire drills. Beginning in September 2017, the Center has implemented protocol that monthly unannounced fire drills will utilize will alternative exit routes throughout the licensing year and will accurately document which exits were utilized during the execution of the fire drill. Oversight to ensure this is being completed will be provided by the Outpatient Assistant Director monthly. |