INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on March 25 - 26, 2013 by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site licensing inspection, Open Door Counseling at Mazzoni 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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705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on observation during a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The findings include:
On March 25 - 26, 2013, a physical plant inspection was conducted. It was observed on these two days that the facility's one unisex bathroom was not clean and sanitary. The toilet was soiled and the bathroom had a foul odor.
The Project Director confirmed the findings.
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Plan of Correction
Program Director spoke with Facility Manager who is responsible for maintenance and upkeep on the shared bathroom at the William Way Center. Mazzoni Center is a tenant of the William Way Center. The Facility Manager is aware of the concerns about keeping the bathroom in a more orderly, tidy manner and has agreed to do so. Program Director will monitor for compliance doing random spot checks on a quarterly basis beginning immediately. |
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 facility's fire drill log, the facility failed to alternate exit routes during fire drills.
The findings include:
On March 25, 2013, the facility's fire drill log was reviewed covering the period of May 2012 through March 2013. The facility failed to prepare alternate exit routes during fire drills during ten out of ten months.
The facility documented on all of the fire drill logs "Emergency evacuation for 1st floor using the front stairs. Proceed to sidewalk across the street from building."
The Project Director did not dispute the findings.
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Plan of Correction
Program Director will institute alternative routes for fire drills starting immediately. In preparation of this, Program Director will hold meeting with staff on 4/15/13 to review plans for the use of alternate exits during fire drills. All future fire drills will reflect alternate exits for evacuation. |