INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22 - 23, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Horizons Treatment 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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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection conducted on January 22, 2014, the facility failed to ensure that exits from the nonresidential facility were unobstructed and operable at all times.
The findings include:
A physical plant inspection was conducted on January 22, 2014. At approximately 4:15 PM, the glass entrance door to the facility was observed to have a double keyed deadbolt lock. This lock would prevent the front door from being operable at all times. The facility failed to ensure that exits from the nonresidential facility were unobstructed and operable at all times.
The project director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Project Director will contact the building owner and ensure that the lock on the front entrance is replaced with a mechanism that meets DDAP licensing requirements.
Furthermore the Project Director will ensure on a daily basis that no entrance/exit in the building is obstructed and that each entrance/exit remains fully operational during hours of operation.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records, the facility failed to maintain a fire drill record including whether the fire alarm or smoke detector was operative.
The findings include:
Fire drill records were reviewed on January 22, 2014. The facility failed to maintain a fire drill record including whether the fire alarm or smoke detector was operative for the fire drills conducted from July 2013 through January 2014.
The project director confirmed the findings.
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Plan of Correction
The Project Director corrected this form during site visit to ensure that adjustments were acceptable. A column was added to the existing Fire Drill Log which prompts staff conducting monthly drills to document whether the fire alarm was/was not operable by checking appropriate box on form.
The Fire Drill Log is part of the agency's overall Health & Safety Program which is monitored quarterly for compliance by the Project Director and the Performance Improvement Committee. Thus the Fire Drill Log will be monitored quarterly to ensure accurate documentation of monthly drills are occurring. |