INITIAL COMMENTS
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This report is a result of an on-site follow-up investigation to an Incident Report conducted on September 27, 2016 by staff from the Division of Accountability and Program Improvement . Based on the findings of the on-site follow-up, the incident which occured at Gaudenzia West Shore Outptient was handled appropriately however; additional findings were identified on-site. Therefore, the facility 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 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on the physical plant inspection that was conducted on September 27, 2016, it was observed that the facility failed to light interior exits and stairs at all times.
It was noted during the physical plan inspection that there were two emergency exit lights that failed to light, one near the entrance and one near the Program Supervisor's office.
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Plan of Correction
Effective immediately, a staff person has been assigned as the Facility Maintenance Representative and they will conduct a monthly facility walk through to determine physical plant needs. The report will be submitted to the Admin. Manager and oversight will be done by the Program Supervisor and Program Director.
Gaudenzia's Physical Plant Manager replaced the lighting on the two interior emergency exit lights as of 9/28/16. |
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
Based on the physical plant inspection that was conducted on September 27, 2016, it was observed that the facility failed ensure fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
It was noted during the physical plan inspection that there were two fire extinguishers, one near the entrance and one near the staff restroom, that had exceeded the timeframe of more than a year since their last inspection and approval.
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Plan of Correction
Effective immediately, the facility has named a Facility Maintenance Representative who will conduct a monthly facility walk through to determine physical plant needs.
This monthly report will be turned in to the Admin. Manager and oversight will be conducted by the Program Supervisor and Program Director.
Fire extinguishers will be monitored monthly in order to contact the vendor when the extinguishers are about to expire.
All three fire extinguishers have been serviced as of 9/30/16 by our approved vendor and will now correspond with the expiration date for 2017.
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