INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 16, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Community Service Foundation 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 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. All fire extinguishers were last inspected by the fire extinguisher company in May 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. Based on a physical plant inspection, all fire extinguishers were last inspected and approved by the fire extinguisher company in May 2024. The facility had the fire company out on the afternoon of December 16, 2025 and all extinguishers were inspected and approved at that time. Clinical supervisor will ensure all staff make sure all extinguishers are inspected and approved annually. This will be done through staff training on fire safety. The facility will be compliant by 12/16/2025. |