INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 26, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Visualize Change, LLC 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) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of a fire extinguisher upon staff employment, in two of two personnel records reviewed.The findings include:Two personnel records were reviewed on January 26, 2016, two of which were for newly hired staff. The facility failed to document the completion of fire extinguisher training upon employment in personnel records #1 and # 2 with in seven days of hire.Employee #1 was hired on May 21, 2015. The training was not documented until 1/22/2016. Employee #2 was hired on May 21, 2015. The training was not documented until 1/20/2016. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will be responsible for making sure this POC is followed-all new employees will receive training upon hire.
All future new employees will be have fire extinguisher training upon hire. This will be documented on the New Employee Orientation Sheet. The training will be done by the borough Fire Chief or another designee that has the appropriate training.
Counselor was hired on May 21, 2015 and received fire extinguisher training on January 20th, 2016 and Facility Director was hired May 21, 2015 and received fire extinguisher training on January 22nd, 2016.
Both individuals involved with Visualize Change, LLC, counselor and Facility Director have received appropriate training on the operation of fire extinguishers for the next facility inspection. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's fire drill log, the facility failed to set off a fire alarm or smoke detector during each fire drill.The findings include:The facility's fire drill log was reviewed on January 26, 2016. The facility failed to set off a fire alarm or smoke detector during fire drills for the following months; June 2015, July 2015, August 2015, September 2015, October 2015 and December 2015.These findings were discussed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director is responsible for assuring the smoke alarms are in working order and all drills are conducted once per month.
Letter requesting an exemption for 705.28 (d) (7)- Fire safety. (d) Fire drills. The nonresidential facility shall: (7) Set off a fire alarm or smoke detector during each fire drill, has been submitted and is awaiting approval. The letter addressing this exception was sent on Feb 12th, 2016.
If the exception request is not granted, facility will follow the licensing guidelines.
The Facility Director will set off a portable bell to indicate a fire drill is being conducted. Monthly fire drills will be completed and documented.
The fire system will be checked annually by the local fire department and will be documented on the fire drill log. |