INITIAL COMMENTS
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This report is a result of an initial on-site physical plant inspection regarding a facility relocation. The inspection was conducted on November 9, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the physical plant inspection, Alliance Medical Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility, specifically 28 Pa. Code Subsection 705.1.
Since this was a physical plant inspection regarding a facility relocation, not all regulations were reviewed. During future inspections, all regulations will be reviewed for compliance.
The following deficiencies were identified.
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Plan of Correction
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705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to provide soap in three of the bathrooms.
The findings include:
A physical plant inspection was completed on November 9, 2015. At the time of the physical plant inspection, soap was not available in three of the bathrooms.
These findings were reviewed with facility staff during the physical plant inspection.
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Plan of Correction
Facility Director will supply all bathrooms with handsoap by 11/17/2015. All supplies will be monitored by the maintenance staff and ordered monthly by Director in order to maintain supplies at all times. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility did not have an exhaust fan or window in the bathrooms.
The findings include:
A physical plant inspection was completed on November 9, 2015, the facility failed to ventilate the bathrooms by an exhaust fan or window.
These findings were reviewed with the facility staff during the physical plant inspection.
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Plan of Correction
Facility Director notified the landlord of the exhaust fan problem on 11/9/15. All fans were inspected same day and repairs are being made. Finalization of repairs will be completed by 11/19/15. Monthly physical plant inspections will be conducted once facility is established in that location and ongoing repairs made as needed. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
Based on a physical plant inspection, the facility failed to maintain a well-secured handrail on the exterior steps. In addition, the facility failed to maintain a well-secured railing for the area that has over an 18 inch drop.
The finding include:
A physical plant inspection was completed on November 9, 2015. At the time of the inspection, there were six exterior steps that did not have a well-secured handrail, and a drop that was more than 18 inches that does not have a well-secured railing.
These findings were reviewed with the facility staff during the physical plant inspection.
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Plan of Correction
Facility Director notified landlord of the missing handrail on 11/9/15. Landlord's maintenance staff installed a new handrail on 11/13/15. However, the exit associated with this handrail will not be used as an exit as sufficient exits exist as per regulation in other parts of the facility. Emergency floor plan signs will be amended to remove this exit from the plan and a "Not an Exit" sign will be placed on the door. |
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 a physical plant inspection, the facility failed to light interior exits at all times.
The finding include:
A physical plant inspection was completed on November 9, 2015. At the time of the inspection, the hallway leading to the exit was not lit.
These findings were reviewed with the facility staff during the physical plant inspection.
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Plan of Correction
Facility Director notified the landlord of the burnt our lights in the emergency exit hallway on 11/9/15. Landlord's maintenance staff replaced bulbs same day. Monthly building inspections will be conducted to ensure all lights are operational and replaced when needed. |
705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical plant inspection, the facility failed to maintain a minimum of four fire extinguishers.
The finding include:
A physical plant inspection was completed on November 9, 2015. The facility was required to maintain four fire extinguishers for the 8000 square feet. At the time of the inspection, there were three fire extinguishers.
These findings were reviewed with the facility staff during the physical plant inspection.
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Plan of Correction
Facility Director contacted Blue's Fire Extinguisher Co on 11/9/15. An extra extinguisher was added to the facility and all extinguishers were inspected as per regulation. Monthly building inspections will be done to ensure that all extinguishers are charged. Annual extinguisher inspections will be done via the above mentioned company. |
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 a physical plant inspection, the facility failed to maintain an annual inspection of fire extinguishers.
The finding include:
A physical plant inspection was completed on November 9, 2015. The facility was required to maintain an annual inspection of the fire extinguishers. At the time of the inspection, the inspection tag documented two inspections, March 2014 and November 2014. It was unable to be determined when the inspections occurred.
These findings were reviewed with the facility staff during the physical plant inspection.
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Plan of Correction
Facility Director contacted Blue's Fire Extinguisher Co on 11/9/15. They serviced all extinguishers same day. Monthly building inspections will be conducted to ensure all extinguishers are operational. Annual inspections and service will be condcuted by above named company. |