INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 5, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Za ' Kiyah House 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 the facility ' s fire drill logs for the months of November 2024 through May 2025, the facility failed to maintain a written fire drill record including documentation of the time of the drill, 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, documentation of any problems encountered during the fire drill, and whether the fire alarm or smoke detector was operative for all months reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Steps
Facility Director
Update fire drill log forms to include all required fields by 6/13/2025
Train staff on proper documentation procedures by 6/13/2025
Review past records and add clarifying notes where possible
Check logs monthly to ensure completeness
Executive Director
Approve new forms and training materials
Verify staff training is completed
Review logs monthly for accuracy
Ongoing Monitoring
Monthly reviews by Facility Director and Executive Director
Quarterly audits of fire drill records
All documentation retained in compliance files |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the facility's fire drill log for the months of November 2024 through May 2025, the facility failed to conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts. All fire drills were conducted on the first day of each month.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Steps
Facility Director
Develop a rotating fire drill schedule to ensure drills are conducted on different days of the week, at varying times (including evenings), and across all staffing shifts.
Train staff immediately on the new scheduling requirements and procedures.
Maintain detailed documentation of each drill, including date, time, shift, and participants.
Monitor and verify that drills follow the varied schedule moving forward.
Executive Director
Approve the rotating schedule and training materials.
Oversee implementation to ensure compliance.
Review fire drill records monthly to confirm drills are being conducted as required.
Retain records and be prepared to share documentation with licensing representatives.
Ongoing Monitoring
The Facility Director and Executive Director will conduct monthly reviews of fire drill logs.
A quarterly audit will verify drills are varied by day, time, and shift.
Any issues identified will be corrected immediately. |