INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 9-11, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Crawford County Drug and Alcohol Executive Commission, 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 and a plan of correction is due on July 9, 2008.
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Plan of Correction
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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 the review of the fire drill logs, the facility failed to document that alternative exit routes were used during the fire drills. The facility used both of the two exits during each fire drill.
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Plan of Correction
Fire drills are conducted on a monthly basis. The facility director will designate which exits are to be used during a fire drill and exits used will be alternated to insure staff are familiar with all exits. Appropriate documentation on exits used will be maintained on the monthly Fire Drill logs.
The corrective plan of action will be implemented 7-1-08 |