INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 7, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Licensure Programs. Based on the findings of the on-site inspection, Discovery House - NC, 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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705.28 (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 include whether the fire alarm or smoke detector was operational on three logs, dated August 26, 2020, October 16, 2020 and December 21, 2020.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinic director will meet with the health and safety captain and team to go over the proper way to conduct a fire drill The director will go over the fire drill form and the proper boxes to check that the fire drill including checking that the fire alarm was activated at the start of the drill. This will be done by the end of March 2021. |