INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 3, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, The Care Center dba SPHS Care Center 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) (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.
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Observations
The facility failed to prepare exit routes to be used during fire drills.The fire drills logs were reviewed on March 3, 2020. All of the fire drills documented from February 2018 - February 2020 utilized the same exit routes.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Safety Regulation 705.28 was reviewed with supervisor on 03/04/2020.
Effective 03/09/2020 supervisor will begin using updated fire drill log that identifies routes utilized and utilize different routes for each drill. Clinical Director will be responsible for ensuring that the procedure was followed through adequately. |