INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16-19, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, CEN-Clear Child 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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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill records, the facility failed to prepare alternate exit routes to be used during fire drills.
Fire drill records were reviewed from April 2023 to March 2024. All fire drills conducted during this time period utilized front door exit only.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Expectations for fire drills outlined in 705.28(d) were reviewed with lead departmental assistants and departmental assistants during a departmental meeting on 5/7/24. Lead Departmental Assistants will audit fire drills completed on a monthly basis to ensure that exits utilized are varied. Where exits being used are not varied, Lead Departmental Assistant will conduct an additional fire drill to ensure opportunities exist to utilize different exits. |