INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 12, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gratitude House 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) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 the review of fire drill logs from August 2021 through July 2022, the facility failed to document exit route used during the drills conducted September 2021 through February 2022.
This is a repeat citation from the July 29, 2021 annual licensing inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Maintenance team was addressed and retrained on fire drill protocal and proper documentation on 8/24/22. Executive Director and risk leader will monitor monthly fire drills for complaince and will address any ongoing areas of concern. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs from August 2021 through July 2022, the facility failed to document if a fire alarm or smoke detector was set off during the drills in March and April 2022.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Maintenance team was addressed on proper fire drill procedures and documentation on 8/25/22 during a training. Executive Director and risk leader will moniotr monthly for ongoing compliance. |