INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 9, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, WPIC Center for Psychiatric and Chemical Dependency 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 (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 the fire drill logs, the facility failed to maintain a written fire drill record that included the number of persons in the facility at the time of the drill.
The fire drill logs were reviewed for August 2021 - July 2022. The names of the staff that participated in the drills were recorded; however, the number of clients in the facility at the time of the drills were not documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Under the direction of the Facility Director or designee:
A. Fire drill logs will document the number of staff and patients who participated in the drill.
B. Supervisors will review fire drill logs monthly to ensure this documentation is noted. |
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 fire drill logs, the facility failed to prepare exit routes to be used during fire drills.
The fire drill logs were reviewed for the period of August 2021- July 2022. The same exit was used for all the fire drills conducted during that time period. There was no documentation that any alternate exits were used.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Under the direction of the Facility Director or designee:
A. Documentation of alternate exits during fire drills will be noted in the fire drill log.
B. Supervisors will review monthly fire drill logs to ensure this information is recorded. |