INITIAL COMMENTS
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This report is a result of an on-site physical plant inspection conducted for a capacity increase request. The inspection was conducted on May 6, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Eagleville Hospital 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection and staff interview, the facility failed to ensure privacy so that counseling session cannot be seen outside the counseling room.
The findings include:
A physical plant inspection was conducted on May 6, 2011 between the hours of 12:15 p.m. and 1:20 p.m. The facility failed to ensure that there were window coverings in place. The conference room, the head psychiatrist's office ( Room 107-B), exam room (Room 107-C), and the lounge area at the end off the hall (by the emergency exit), failed to have window coverings in place so that counseling sessions cannot been seen outside the room.
Staff interview confirmed these findings.
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Plan of Correction
A film was added to the windows in the conference room and the end of the hallway that allows individuals inside the building to look out, but prevents anyone outside the building from looking in. Counseling will not be conducted in the hallway area, and counseling will not be conducted in the conference room in the evenings/nights. The windows in the psychiatrist's office and the exam room were temporarily frosted to ensure privacy of those inside during both day and evening/night hours. The frosted windows were replaced with touch blinds (no cords). These blinds were installed on 5/20/11. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection, the facility failed to provide slip resistant surfaces in seven of eight bathroom showers.
The findings include:
A physical plant inspection was conducted on May 6, 2011. All showers are required to have slip resistant flooring. The facility did not provide slip resistant flooring in the showers in rooms # 102, 103, 141, 143, 144, 146, and 147.
Staff confirmed these findings.
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Plan of Correction
Non-skid strips have been added to all showers that lacked slip resistant flooring. Showers will be checked quarterly by the Director of Plant Operations during his physical plant inspections to ensure that any non-skid strips that need replacing are identified and replaced. |