INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 23, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, McDermott Counseling, LLC 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 fire drill logs the facility failed to maintain a written fire drill record including exit route used.
A review of fire drill logs from January 2024 - November 2024, revealed that the facility is not documenting the exit route used during each evacuation. All fire drills noted "first floor" as the exit route.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Beginning 2025 Fire drills will document the number of people on site at time/day of drill. Any problems encountered during the fire drill will be documented. The duration of the fire drill will be documented. Smoke alarms will also be checked. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs the facility failed to prepare alternate exit routes to be used during fire drills.
A review of fire drill logs from January 2024 - November 2024, revealed that the facility is not documenting the use of alternate exit routes.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Beginning 01/06/2025 fire drill documents will include which exit was utilized. There are two exits from first floor office. Fire drill will include which exit was exited during the fire drill. The 2 exits will be named east and west exit-the exits will alternate with each fire drill. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of fire drill logs the facility failed to conduct fire drills on different days of the week.
A review of fire drill logs from January 2024 - November 2024, revealed that the facility is conducting its fire drills on a Monday.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Beginning 01/06/2025 fire drills will be conducted on different days of 7-day work week and different times throughout the day. The staggered times and days will be documented in fire drill log. |