INITIAL COMMENTS
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This report is a result of an on-site review and physical plant inspection conducted for a capacity increase request. The inspection was conducted on July 28, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Soar Corp. 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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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. The findings include:A physical plant inspection was conducted on July 28, 2014. The following cleanliness or sanitation issues were noted during the inspection:1) The hallway walls of the 1st and 2nd floors of the main facility were not clean. 2) The large group room on the second floor had brown stained ceiling tiles, the walls were dirty, and there was a hole in the wall. 3) The small group room on the second floor had walls that were not clean, brown stained ceiling tiles, and an accumulation of dust on two vents and the ceiling tiles surrounding the vents.These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
All of the identified issues were addressed by August 4th, 2014. The cleaning company cleaned entire building and construction crew was brought in to paint facility, fix hole in wall, clean all air ducts/vents along with new ceiling tiles added wherever needed throughout the facility. In addition to this, new lights were put in throughout the first and second floors where needed. The Health and Safety Team will do a monthly inspection of physical plant. Identified deficiencies will be addressed as identified by the Health and Safety Team. List of deficiencies will be forwarded to SOAR VP for immediate attention. Director will oversee for compliance throughout the year. |
705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on a physical plant inspection, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.The findings include:A physical plant inspection was conducted on July 28, 2014. The facility failed to cover the dumpster and trash cans that are located in the main parking lot. Trash was observed on top of the open dumpster and an uncovered can. At the time of the inspection, wind swept through the dumpster and uncovered can and deposited trash throughout the parking lot.These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
The dumpster located at the rear of the building is for all the tenants of this building (including SOAR). The dumpster is the responsibility of the building owner. Nonetheless, SOAR VP contacted the new building owner to address the issue. Since that time, a new dumpster, which closes properly, was delivered and moved to the corner of the parking lot with an enclosed fence built around it. The building owner will monitor the dumpster weekly. The SOAR Health and Safety Team will monitor as well. Project Director is responsible to ensure compliance during the course of the year. |
705.24 (1) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(1) Provide bathrooms to accommodate staff, clients and other users of the facility.
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Observations
Based on a physical plant inspection, the facility failed to provide a wall mirror and an operable soap dispenser in each bathroom. The facility also failed to provide hot water in each bathroom, failed to ventilate each bathroom by exhaust fan or window and failed to maintain each bathroom in a functional, clean and sanitary manner at all times. The findings include:A physical plant inspection was conducted on July 28, 2014. The facility failed to provide the following items as of the time of inspection on July 28, 2014:1) One of two bathrooms in Suite 1 did not have a wall mirror or an operable soap dispenser. 2) The 2nd floor, client bathroom in the main facility did not have hot water under pressure. 2) The exhaust fan in one of two bathrooms in Suite 1 was not operable and there was no window. 3) The two unisex client bathrooms in the main building had an odor and the floors were not clean. The 1st floor bathroom had an elevated floor around the toilet that had yellow colored stains and the toilet paper holder in the same bathroom was broken.These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
All of the bathrooms currently have a mirror and an operable soap dispenser. The monthly inspection by the Health and Safety Team will include this as part of their inspection. All exhaust fans are now operable and will also be included in the monthly inspection. These were fixed by the construction team brought in to do all of the other work. The hot water problem was also corrected at the same time and will be monitored by the Health and Safety Team on a monthly basis. All floors in the bathrooms were cleaned, walls painted and broken toilet paper roll holders replaced where needed. The Health and Safety Team along with the Project Director will monitor these areas for compliance throughout the year. When the Monthly inspection identifies deficiencies they will be immediately forwarded to SOAR VP and Project Director so they can be immediately addressed/fixed. |