INITIAL COMMENTS
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This report is a result of an initial on-site licensure inspection conducted on July 25, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Retreat at Lancaster County, PA - 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 inspection:
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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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection, the facility failed to provide furnishings for the living rooms and lounges.
The findings were:
An initial physical plant inspection was conducted on July 25, 2011. The living rooms and lounges identified on the second, third and fourth floors of the main residential building, and in the counseling building, were devoid of furniture.
This was addressed with the project director who did not dispute the findings.
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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. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ensure that there were operable windows or exhaust fans in all bathrooms.
The findings were:
A physical plant inspection was conducted on July 25, 2011. Public bathrooms on the first floor of the main residential building, in the gymnasium and in the counseling building did not have operable exhaust fans and did not have functional windows.
The project director did not dispute the findings.
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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. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to ensure that each bathroom was maintained in a functional and sanitary manner at all times. One of the bathrooms in the main residential building and one of the bathrooms in the gymnasium were still under construction and were not clean and sanitary.
The findings were:
One bathroom on the third floor of the main residential building was still undergoing maintenance and repairs. One bathroom in the gymnasium was still undergoing maintenance and repairs. Neither bathroom was clean and sanitary as construction was ongoing.
The findings were discussed with the project director and he did not dispute the findings.
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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. |
705.7 (a) LICENSURE Food service.
705.7. Food service.
(a) A residential facility shall provide meals to residents through onsite food preparation areas, a central food preparation area or contractual arrangements with vendors or caterers.
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Observations
Based on a physical plant inspection, the facility failed to provide for a clean and furnished dining area.
The findings include:
A physical plant inspection was conducted on July 25, 2011. At the time of the inspection, the dining area was still undergoing maintenance and repairs. The dining room was not furnished and was not in a condition to begin providing services to residents.
The project director did not dispute the findings.
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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. |
705.7 (b) (2) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(2) Clean and disinfect food preparation areas and appliances following each prepared meal.
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Observations
Based on a physical plant inspection, the facility failed to provide for clean and disinfected food preparation areas and appliances.
The findings were:
The commercial kitchen was still under construction and was not ready to begin operations at the time of the inspection on July 25, 2011.
The project director did not dispute the findings.
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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. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on the physical plant inspection, the facility failed to ensure that the refrigerator was at or below 40F and that the freezer was at or below 0F.
The findings were:
A physical plant inspection was conducted on July 25, 2011 at which time the temperature gauge on the refrigerator was reading above 40F and the temperature gauge on the freezer was reading above 0F.
The project director did not dispute the findings.
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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. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that exits were unobstructed. Internal stairways in the main residential building were obstructed due to ongoing construction. Two bathrooms in the counseling building were equipped with exterior key locks.
The findings were:
A physical plant inspection was conducted on July 25, 2011. During the inspection of the main residential building, construction workers were completing work on the interior stairways and in the process obstructing the exits. Two of the bathrooms in the counseling building were equipped with key locks on the outside of the doors and no thumb latches on the inside of the doors. This situation posed the possibility of someone being accidentally locked in the bathrooms. The physical plant was not in a condition to begin providing services.
This was discussed with the project director who did not dispute the findings.
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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. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure that the fire suppression system over the commercial gas stove in the facility kitchen had been inspected within the last twelve months.
The findings were:
A physical plant inspection was conducted on July 25, 2011. The fire suppression system for the commercial gas stove in the kitchen had not been inspected by a fire equipment company or the local fire department in the last twelve months.
This was discussed with the project director who did not dispute the findings.
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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. |