INITIAL COMMENTS
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This report is a result of an on-site initial licensure inspection conducted on December 30, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Freedom Healthcare Services 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:
As this was the initial inspection conducted, not all regulations were reviewed. During future inspections, all regulations will be reviewed for compliance.
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Plan of Correction
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705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on the physical plant inspection, the facility failed to maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
The findings include:
A physical plant inspection was conducted on December 30, 2015. An inspection of the basement revealed that the stairs were the only exit from the basement. There was only one exit from the basement.
These findings were reviewed with facility staff during the initial inspection process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (a) (1) (iv) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on the physical plant inspection, the facility failed to clearly indicate exits by use of signs.
The findings include:
A physical plant inspection was conducted on December 30, 2105. An exit door in the back of the facility was not marked as an exit.
These findings were reviewed with facility staff during the initial inspection process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on the physical plant inspection, the facility failed to light interior exits and stairs at all times.
The findings include:
A physical plant inspection was conducted on December 30, 2015. The facility failed to light the stairs leading to the basement.
These findings were reviewed with facility staff during the initial inspection process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on the physical plant inspection, the facility failed to display conspicuously to the general public the hours of project operation.
The finding include:
A physical plant inspection was completed on December 30, 2015. There was no posting of the hours of operation displayed conspicuously to the general public.
These findings were reviewed with facility staff during the initial inspection process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on the physical plant inspection, the facility failed to display conspicuously a telephone number for the general public for emergency purposes.
The findings include:
A physical plant inspection was completed on December 30, 2015. There was no telephone number displayed conspicuously to the general public for emergency purposes.
These findings were reviewed with facility staff during the initial inspection process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |