This report is a result of an initial on-site licensure inspection conducted on March 4, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, St. Joseph Institute, 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 and a plan of correction is due on March 16, 2010.
Since this was the initial inspection conducted, not all regulations were reviewed. During future inspections, all regulations will be reviewed for compliance.
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Plan of Correction
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Observations
Based on a physical plant inspection conducted during the initial inspection and a phone conversation with the Chief Executive Officer and a review of basement schematics, the facility failed to ensure that there were at least two means of egress from the basements in the Spruce Lodge, the Laurel Wellness Center and the Appalachian Lodge.
The findings include:
The physical plant inspection was conducted on March 4, 2010. The basements in Sycamore Lodge and the Bald Eagle Hospitality House were included in the inspection. The Licensing Specialist was not aware of the existence of basements in Spruce Lodge, the Laurel Wellness Center and the Appalachian Lodge. Facility staff did not make the Licensing Specialist aware of the existence of those basements. During a review of the licensing material on March 8, 2010, a schematic for the basement of Spruce Lodge was observed. The schematic clearly showed only one means of egress from that level. A phone conversation with the Chief Executive Officer on March 8, 2010 confirmed that there were basements under Spruce Lodge, Appalachian Lodge and the Laurel Wellness Center and that each of these basements had only one means of egress. Basements and attics not having two exits cannot be used for any reason, including storage, and must be locked at all times.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |