INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 22, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Guidance For Growing, 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 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential 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 an inspection of the facility's physical plant, the facility failed to ensure that all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company in two of two extinguishers observed.
The findings include:
A physical plant inspection was conducted on April 22, 2015 at approximately 8:15 am. During the inspection, it was found that the fire extinguisher next to the front door exit and the fire extinguisher next to the rear door exit were last inspected in April 2013, which resulted in an expiration date of April 30, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will be responsible for maintaining inspection of all fire extinguishers in the building every 1 year (as fire extinguisher expiration is 2 years). Any extinguisher set to expire within 6 months will result in the clinical supervisor notifying the building manager. The current extinguishers will be updated by 6/2/2015. The clinical supervisor will check to ensure the fire extinguisher is replaced before the expiration date. The extinquishers will be inspected by the clinical supervisor every June of each year. |