INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 11, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mercy House of Meadville, Inc. 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 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
All fire extinguishers were last inspected and approved July 2022.
These findings were reviewed with facility staff during licensing process.
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Plan of Correction
Facility Director relied on building owner for yearly inspection to co-occur with the main building. The owner failed to inspect. Facility director has arranged inspection to occur Thursday March 28th, 2024. and will note completion and appointment date in fire drill log. Facility director will arrange with company directly for future service and make notation on the fire drill log. |