INITIAL COMMENTS
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This report is a result of an initial, on-site, licensing inspection conducted on January 29, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the initial inspection, Two Roads Counseling Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
Since this was the initial inspection conducted, not all regulations were reviewed. During future inspections, all regulations will be reviewed for compliance.
The following deficiencies were identified.
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Plan of Correction
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705.28 (b) (4) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(4) Maintain a manual fire alarm system that is audible throughout the facility.
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Observations
Based on a physical plant inspection, the facility failed to maintain a manual fire alarm system that is audible throughout the facility.
The finding include:
An initial, on-site, physical plant inspection was completed on January 29, 2016. The facility is located on the third floor of the building. At the time of the inspection, a manual fire alarm system is on the first and second floor of the building, but is not on the third floor.
These findings were reviewed with the facility staff during the initial, on-site physical plant inspection.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on an initial, onsite, physical plant inspection, the facility failed to maintain a minimum of two fire extinguishers.
The finding include:
An initial, onsite, physical plant inspection was completed on January 29, 2016. The facility was required to maintain two fire extinguishers for the 3686 square feet on the third floor. At the time of the inspection, there was one fire extinguisher.
These findings were reviewed with the facility staff.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |