INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 17, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, CPP Behavioral Health 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) (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 records, the facility failed to maintain a written fire drill record including the problems encountered and whether the fire alarm or smoke detector was operative.
The findings include:
Fire drill records for December 2013 through June 2014 were reviewed on July 17, 2014. The facility failed to maintain a written fire drill record for December 2013 through June 2014 that included the problems encountered and whether the fire alarm or smoke detector was operative.
The Business Operations Manager was interviewed on July 17, 2014 and did not dispute the findings.
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Plan of Correction
The written fire drill record has been revised to include data collection for problems encountered during monthly fire drills and for the operational status of the fire/smoke alarm.
The Project Director or designee will now document any problems or issues that occur during the monthly fire drills and also document the operational status of the fire or smoke alarm. |