INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 7, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Deerfield Center for Addictions Treatment 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 and a plan of correction is due on May 4, 2010.
|
Plan of Correction
|
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of the fire drill logs and an interview with the Clinical Supervisor, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill logs were reviewed on April 6, 2010. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. The facility did not document any alternate exits used during fire drills. The front door was the exit route used during every fire drill.
On April 7, 2010, the Clinical Supervisor was interviewed and confirmed that the only exit used for fire drills was the front door.
|
Plan of Correction
The Program Director or Clinical Supervisor will send a letter to the office manager within one week requesting documentation regarding the date the fire alarm/smoke detector system was tested. In addition the Program Director will request that a copy of the annual testing report be sent to him so that it can be added to the Policy and Procedure manual. |
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.
|
Observations
Based on a review of fire drill logs and an interview with the Clinical Supervisor, the facility failed to document the fire alarm/smoke detector system was operational.
The findings include:
The fire drill logs were reviewed on April 6, 2010. Per regulation, the nonresidential facility shall set off a fire alarm or smoke detector during each fire drill. The facility has an exception to this regulation. This exception requires documentation of an annual test of the fire alarm/smoke detector system and documentation that the system is operational. The facility could not provide documentation of an annual inspection of the fire alarm/smoke detector system or documentation that the system is operational.
The Clinical Supervisor was interviewed on April 6 and April 7, 2010. The Clinical Supervisor reported that she did not have documentation of an annual test of the fire alarm/smoke detector system.
|
Plan of Correction
The Program Director or Clinical Supervisor will send a letter to the office manager within one week requesting documentation regarding the date the fire alarm/smoke detector system was tested. In addition the Program Director will request that a copy of the annual testing report be sent to him so that it can be added to the Policy and Procedure manual. |