INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 8-11, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Alcohol and Drug Abuse 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) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill records, the facility failed to set off a fire alarm or smoke detector during each fire drill.
Fire drill records were reviewed from July 2023 to June 2024. Fire drills documented from October 2023 and June 2024 did not indicate that a fire alarm or smoke detector was set off during the fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Deputy director or designee will re-educate all Port Allegany staff on regulation 705.28 Fire Safety (d) Fire drills - The nonresidential facility shall:(7) Set off a fire alarm or smoke detector during each fire drill. This education will be complete by August 31, 2024. Audits will be completed monthly starting September 2024 by the Deputy Director or designee. Once 100% compliance is met quarterly audits will be completed by the Deputy Director or designee. |