INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 22, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Family Services of NW PA 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 the staffing records, the facility failed to ensure all personnel were instructed in the use of fire extinguishers upon employment in four of four records reviewed.
Staff #1 was promoted to project director on March 13, 2025 and still employed at the time of inspection. Frie extinguisher training was not completed until October 8, 2025.
Staff #2 was hired as a counselor on April 25, 2025 and still employed at the time of the inspection. Fire extinguisher training was not completed until October 9, 2025.
Staff #3 was hired as a counselor on June 16, 2025 and still employed at the time of the inspection. Fire extinguisher training was not completed until October 9, 2025.
Staff #4 was promoted to counselor on June 1, 2025 and still employed at the time of the inspection. Fire extinguisher training was not completed until October 9, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Current staff completed identified fire extinguisher training on October 9, 2025. All new staff members will complete fire extinguisher training within 6 days of hire. This has been added to the Human Resources Orientation onboarding requirements. New employees will receive a training alert in their email from the Relias training system that indicates they have been assigned the "Fire Prevention and Response: The Basics Self-Paced". Relias system will alert the supervisor and employee via email if the training is not completed by the assigned date. This was added to the onboarding assignments by HR director on 10/29/25. HR Director verified to D&A Program Director that the alerts are showing for new employees. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 conduct unannounced fire drills once a month.
Reviewed fire drill records from April 2025 to October 2025. No fire drills were conducted from April 2025 to September 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
FSNWPA facility shares the building with Great Lakes Institute of Technology (GLIT) and Griffith Properties owns the building. Griffith Properties property manager was contacted by FSNWPA MIS/Maintenance Supervisor regarding the frequency of fire drills required for licensing. Griffith Properties Property manager has agreed to conduct fire drills monthly, allowing FSNWPA to comply with this regulation. Property Manager confirmed that they would conduct these fire drills monthly via email on October 23, 2025. FSNWPA MIS/Maintenance Supervisor will monitor the frequency and completion of monthly fire drills and submit completed documentation to the Facility Director. |
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 all regulatory information.
Reviewed fire drill log for October 2025. The fire drill log failed to include the exit route used during the drill.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
FSNWPA MIS/Maintenance Supervisor updated the fire drill log for 10/10/2025 to include exit route used during the drill. The log has been reviewed to ensure that the log will include all necessary requirements. To ensure the same exit route is not taken each time. FSNWPA MIS/Maintenance Supervisor will block a different exit with a fictitious "fire" thus eliminating the use of the same route used each time. The form was updated on 10/27/2025. FSNWPA MIS/Maintenance Supervisor will complete and submit the log to the Facility Director each month. The log will be maintained in the licensing folder in the agency shared drive. |