INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6-7, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, SPHS Behavioral Health 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 (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
The facility failed to document that fire extinguishers were inspected and approved annually.
A physical plant inspection was conducted on February 7, 2020. At the time of the inspection, all of the fire extinguishers observed documented the last inspection as June 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Supervisor coordinated an urgent inspection of the outdated fire extinguishers. Documentation supports that this inspection was conducted on 02/12/2020. Moving forward, the Program Director will incorporate review of fire extinguisher inspection updates as a mandatory check of the agency's internal mock audit process to ensure that every facility's fire extinguisher inspections are updated at least once on an annual basis. |