INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 28, 2014 to January 29, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Service Association of Bucks County 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 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on observations on January 29, 2014, the facility failed to ventilate bathrooms by exhaust fan or window in two of four bathrooms.
The findings include:
A physical plant inspection was conducted on January 29, 2014, 1 men's employee restroom, 1 women's employee restroom, 1 men's public restroom, and 1 women's public restroom were inspected. The following restrooms were not ventilated by an exhaust fan or window:
1)The men's employee restroom at approximately 10:50 A.M.
2)The women's employee restroom at approximately 10:55 A.M.
The findings were confirmed during an interview with the facility director on January 29, 2014 at approximately 10:56 A.M.
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Plan of Correction
Both the men's and women's restrooms are both ventilated by an exhause fan. The fans were not blowing at the time of the inspecition. A request for a maintenance check has been submitted. Based on the results of the maintenance check, repairs will be completed by internal staff or an external contractor. Repairs are expected to be complete by 3/15/14. Moving forward, all restrooms in our facility will be ventilated by exhaust fans at all times during our hours of operation. A routine check of the exhaust fans will be added to Family Service Association's monthly safety check list by 3/15/14 and overseen by the Safety Committee.
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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 fire drill records, the facility failed to maintain a written fire drill record that included documentation of the exit route used during fire drills in four of twelve months reviewed.
The findings include:
Fire drill records were reviewed on January 28, 2014. The records were reviewed from the period covering February 2013 to January 2014. The facility did not have documentation for exit route used in four of twelve months reviewed, specifically, August 2013; September 2013; October 2013; and December 2013.
The findings were presented to the facility director on January 29, 2014 at approximately 3:00 P.M.
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Plan of Correction
The fire drill record log will include documentation of the exit route used for each monthly fire drill. The fire drill record log is reviewed monthly by the Safety Committee. The specific exit route used for the drill will be added to the monthly safety check list by 3/15/14 and overseen by the Safety Committee. This will be the process moving forward to meet compliance with this standard. |