INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on March 13 & 14, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Sojourner House, 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The findings include:
The fire drill logs were reviewed on March 13, 2012. The fire drills conducted between April 2011 and February 2012 were reviewed. Fire drills during sleeping hours are required to be completed at least every 6 months. Two fire drills during sleeping hours were conducted in this time period. They were conducted on 11/15/11 and 12/22/11. Another fire drill during sleeping hours was due to be completed by June 2011.
An interview with the project director was conducted on March 13, 2012 at approximately 3:30 PM. The aforementioned information was confirmed at that time.
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Plan of Correction
Fire drills during sleeping hours will be conducted at least once during each six month time period.
The Operations Coordinator will be responsible to conduct the fire drills with oversight provided by the Executive Director. |