INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on June 18, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Montco Recovery Center LLC, 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 investigation and a plan of correction is required.
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Plan of Correction
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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
The facility failed to document the required information on the facility fire drill logs. Fire drill logs were submitted for the time period November 2019 through February 2020; these logs failed to document the following information: -the amount of time it took for evacuation-the exit route used-problems encountered-whether the fire alarm or smoke detector was operative.
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Plan of Correction
The Safety Officer or designee have begun to complete fire drill logs monthly that include all required items. This facility will be in full compliance with this standard as of June 2020. Periodic checks will be conducted to ensure that the deficiency does not recur. |