INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 21, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. Edinboro Satellite Office 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 fire drill records, the facility failed to maintain a written fire drill record including the exit route used.
The findings include:
Fire drill records for October 2013 through September 2014 were reviewed on October 21, 2014. The facility failed to maintain a written fire drill record including the exit route used for the drills conducted on the following dates: 8/27/14, 6/25/14 and 12/18/13.
The findings were reviewed with the facility director during the licensing process.
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Plan of Correction
Program Director will meet with all clinical staff and review fore drill form and the requirement that route of exit be documented during all fire drills by December 1st, 2014.
Agency Maintenance Supervisor will review all fire drills and review results in the monthly Safety and Sanitation meeting starting in December 2014. |