INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 14, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County 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) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records, the facility failed to conduct unannounced fire drills once a month.
The fire drills were reviewed for the period of November 2023 to October 2024.
No fire drills were conducted during the months of February 2024 and October 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Community Counseling Center will simultaneously conduct fire drills at both locations on a monthly basis and a monthly verification of the monthly drills will be reported to the Program Director/Project Director. |
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 fire drill records, the facility failed to maintain a fire drill record which included all of the required components.
The fire drills were reviewed for the period of November 2023 to October 2024. All fire drills reviewed were missing problems encountered.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 16, 2023 licensing renewal inspection.
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Plan of Correction
Community Counseling Center has created a new fire safety drill log which now includes category of "problems encountered" included with the rest of the required components. A monthly verification of the log will be reported as completed to the Program Director/Project Director. |