INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 6, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, UHS Recovery Foundation 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:
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Plan of Correction
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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 the facility's December 2024 through December 2025 fire drill logs, the facility failed to maintain a written fire drill record, which is to include the documentation of which exit route was used during the fire drill.
At the time of the inspection, the October 28, 2025 fire drill log did not include what exit route was used during the fire drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Plant Operations was reeducated on 1/7/2026 for fully completing the fire drill record. Documentation must include the exit route used for each fire drill.
Ongoing, Director of Plant Operations and Director of Quality Assurance will audit each fire drill record monthly. The compliance of the fire drill record will be reported to the Performance Improvement Committee monthly. |