INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 27, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Sanctuary House, 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:
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Plan of Correction
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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 maintain each bathroom in a functional, clean, and sanitary manner at all times.
The first-floor bathroom, located off the dining room, had what appeared to be mold or mildew in the corner of the bathroom wall and next to the toilet. Additionally, the electrical outlet cover was loose from the wall.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director along with the Governing Body have reviewed Regulations, Licensing Alerts and Sanctuary House Policy and Procedures related to 705.6 Bathrooms and the 2024 Licensing Survey Results. It was decided by the governing body to remodel that bathroom to address the issues. The work started on 9/29/2024 and was completed on 10/09/2024. The walls, toilet, vanity and vinyl flooring were replaced. The walls that were replaced were also painted. The electrical outlet cover was replaced and is secure. Going forward when doing room inspections, the tech on duty will check areas such as corners and behind the toilet weekly for any type of mold or mildew. Visual inspection of all electrical outlets and switches should also be done weekly and any deficiencies should be reported to the Tech Supervisor. The tech supervisor will report any issues to the CFO who will secure the labor to resolve the issue. This issue is considered resolved effective 10/09/24. |
705.7 (b) (4) 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:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
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Observations
Based on a physical plant inspection, the facility failed to ensure that storage areas for foods are free of food particles, dust, and dirt.
The food storage cabinet, located in the first-floor kitchen area, had loose food particles, dust and dirt in it. Additionally, the pantry, located on the second-floor, had loose food particles in it.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director along with the Governing Body have reviewed Regulations, Licensing Alerts and Sanctuary House Policy and Procedures related to 705.7 (b) (4) Food Service and the 2024 Licensing Survey Results. The areas identified in the survey included a lower cabinet that stored cooking pots on the first floor and an upstairs pantry that had spilt sugar on one of the shelves. The lower kitchen cupboard storing the pots and pans was immediately cleaned by the Tech Supervisor. Additionally, the Tech Supervisor wiped the shelf with the spilt sugar, on the second floor. Furthermore, on a weekly basis the tech on duty will check these areas and those of a similar nature to be sure they are wiped down and cleaned. The Tech Supervisor will monitor this for compliance and report any problematic issues to the Project Director. This issue is considered resolved immediately. |
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 the physical plant inspection, the facility failed to ensure all fire extinguishers were inspected and approved annually by the local fire department or a fire extinguisher company.
The fire extinguisher, located in the second-floor kitchen, was not inspected and approved for the current year, as the date of the inspection tag was May 2023.
This finding was reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Project Director along with the Governing Body have reviewed Regulations, Licensing Alerts and Sanctuary House Policy and Procedures related to 705.10 (c) (3) Fire Safety, Fire Extinguisher and the 2024 Licensing Survey Results. The issue identified in the Survey was a Fire Extinguisher located in the corner of the upstairs kitchen often obscured by the open door. Inadvertently this extinguisher was not updated when the other extinguishers were. It had an expired tag. The Counselor removed the extinguisher, had it serviced, and it was returned to its proper location before the inspector left the property. The Tech Supervisor created a map identifying all extinguishers. This map will be kept with the fire drill information so that each location is clearly marked. The map will prevent this issue from occurring again. This issue in considered resolved immediately. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on an administrative review, the facility's governing body failed to make available to the public an annual report, which is to include, but not limited to, a statement disclosing the names of officers, directors, and principal shareholders.
There was no documentation indicating the 2024 annual report was made available to the public as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director along with the Governing Body have reviewed Regulations, Licensing Alerts and Sanctuary House Policy and Procedures related to 709.22 (c) and the 2024 Licensing Survey Results relating to making available to the public an annual report, which is to include, but not limited to, a statement disclosing the names of officers, directors, and principal shareholders. There was no documentation about this at the time of inspection. The governing body contacted a web site designer to develop and launch a website for Sanctuary House LLC. When this is completed the annual report for 2023 will be published there. Projected Completion and Lauch will occur within the next 90 days (01/25/2025). The Project Director provided the CFO with the 2023 Annual Report to be added to web site during its development. The CFO will be responsible for maintaining the Sanctuary House LLC Web Site. The Project Director will be responsible for providing each year's annual report to the CFO for publication. |