INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 25, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Service Foundation, 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) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills were conducted during different times of the day.The findings include:A review of the December 2013 through and including October 2014 fire drill logs was conducted prior to the inspection date and was re-reviewed on November 20, 2014. The facility's hours of operation are from 8:00 a.m. until 4:00 p.m. The facility failed to document fire drills between the hours of 12:35 p.m. and 4:00 p.m. All of the fire drills documented times are 12:35 p.m. or earlier.These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The project director and clinical supervisors will ensure that all programs have monthly fire drills during the hours of operation. The clinical supervisors will review the fire drill log sheet directions on 1/5/15, which state that fire drills must be conducted in all months and should take place during the hours of operation from 8:00am until 4:00 pm with all staff to ensure that this deficiency does not recur. The project director will ensure ongoing compliance by having the clinical supervisors review the fire drill logs in monthly supervisions. |