INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 25- 26, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mon Yough Community Services, 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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705.24 (1) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(1) Provide bathrooms to accommodate staff, clients and other users of the facility.
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Observations
Based on the physical plant inspection, the facility failed to ventilate bathrooms with an exhaust fan or window.
The findings include:
The physical plant inspection was conducted on August 25, 2015 at approximately 1:00 PM. The second floor unisex bathroom was observed to have an inoperable exhaust fan. There was no window present in this bathroom.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A request for repair of the second floor unisex bathroom fan was submitted to the agency maintenance department on 8-26-15. This bathroom fan will be repaired by October 15, 2015 by the agency maintenance staff or contractors to ensure proper ventilation. Bathroom fans will be checked on a monthly basis by the program supervisor to ensure proper functioning. A maintenance request will be submitted within 24 hours if repair is indicated.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill logs, the facility failed to conduct unannounced fire drills at least once per month.
The findings include:
The fire drill logs were reviewed on August 24, 2015. The fire drill log was reviewed from July 2014 to July 2015. There was no documentation of unannounced fire drills conducted for the months of September 2014 and November 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Drills will be conducted on a monthly basis. The program Supervisor and the Office Coordinator who currently conducts the drills will train an additional Office Coordinator on the process of conducting and documenting the drills by September 15, 2015. Each trained Office Coordinator will be responsible for conducting and documenting the fire drills in the absence of the other to ensure that monthly timeframes are not missed. The program Supervisor will ensure that drills are conducted and documented on a monthly basis by reviewing the fire drill log monthly. |