INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted May 7, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, James A. Casey House, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential 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 residents, 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 conducted on May 7, 2024, the facility failed to keep the grounds clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
The following was observed during the physical plant inspection:
Apartment 12
Bedroom 3 is missing plaster on the wall by the light switch and broken door frame with sharp wood exposed.
Bedroom 4 is missing floor tile in the closet and bulging and stained ceiling tiles from prior water leaks, missing ceiling light cover.
Apartment 11
Bedroom 4 has broken blinds.
Apartment 10
Bedroom 1 has a dresser missing a drawer.
Bedroom 2 has a missing knob on the bottom dresser drawer
Bedroom 3 has a broken handle on the dresser drawer and a hole in the ceiling tile
Kitchen has cracked linoleum, cove base is hanging off the wall,water stained/damaged ceiling tile
Bedroom 4 has peeling ceiling tile and broken floor tiles around the door entrance
Apartment 9
Bedroom 1 has cracked and missing floor tiles, and missing a ceiling light cover.
Bedroom 2 has cracked floor tiles.
Kitchen has broken floor tiles.
Living room floor tiles are broken and damaged/bulging ceiling tiles, missing vent cover on the air conditioner.
Apartment 8
Bedroom 1 the blinds did not cover the entire window and had broken slots, windowsill tile was cracked.
Bedroom 2 has cracked floor tile and the window screen was torn and missing floor tile under the bed.
Bedroom 3 has floor tiles and sharp/cracked tile on the windowsill, missing ceiling vent cover, bulging/damaged ceiling tiles, and broken door frame with sharp wood edges exposed.
Apartment 7
Bedroom 1 is missing cover base.
Bedroom 2 cover base is separated from the wall and a cable wire was exposed/hanging from the ceiling.
Kitchen has damaged floor tile.
Bedroom 3 has window blinds that do not cover the entire window.
Apartment 6
Bedroom 1 has damaged wall/hole in drywall.
Bedroom 2 has two damaged/torn chairs.
Kitchen lower cabinet was damaged broken laminate and countertop.
Apartment 5
Bedroom 2 has a missing outlet cover with an exposed sharp piece.
Bathroom 4 has bulging ceiling tile.
Apartment 4
Bedroom 1 is missing a window covering.
Kitchen has cracked/damaged countertops.
Bedroom 3 has a broken door jam and frame.
Apartment 3
Kitchen floor tile was torn/damaged.
Apartment 2
Bedroom 3 has a dresser that is missing the front piece of the drawer.
Bedroom 4 has missing ceiling tile and damaged floor tiles.
Apartment 1
Bedroom 1 has a broken window frame, hole in the ceiling tile.
Bedroom 2 has a broken outlet cover.
Bedroom 3 has cracked floor tiles and a hole in the floor tile.
Kitchen has a torn black chair.
Efficiency apartment 4 has cracked floor tiles, two ripped/torn chairs, missing baseboard heater covers, missing light cover.
Efficiency apartment 3 has cracked/broken floor tile, torn/damaged black chair.The Kitchen is missing an electrical outlet/box cover (wires exposed).
Efficiency apartment 2 has window blinds that are broken/missing slats.
Efficiency apartment 1 has cracked floor tiles and severely stained and torn carpet that was a tripping hazard, broken window blind slats, missing ceiling light covering in the kitchen.
Efficiency apartment hallway has damaged floor and wall plaster near the recently repaired water pipes.
2nd floor hallway has cracked ceiling tiles.
The emergency exit hallway has floor damage at the top of the stairwell. This is a tripping hazard.
On the first floor, the hallway leading to the exit door has cracked flooring, and the elevation change was not indicated which can be a tripping hazard.
Stairwell landing has cracked and missing floor tiles. The covering on the steps was missing and some steps had worn/cracked/missing edges that are a tripping hazard.
The first floor loung has damaged and missing ceiling tiles hanging down.
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Plan of Correction
The Project Director will develop a facility maintenance plan, including developing an updated maintenance log, in order to report, track, and correct physical plant deficiencies. All facility areas will be inspected weekly by the Project Director and/or his designated representative. All deficiencies will be documented in the facility maintenance log. Any deficiencies regarding safety issues will be corrected immediately upon discovery. Following each weekly facility inspection, the maintenance log will be updated and new discrepancies will be reviewed by the Project Director and/or his representative facility maintenance staff. During this review any corrective actions taken by the maintenance staff during the week will be reviewed. The Project Director and/or his representative will perform a follow-up inspection on all corrective actions to ensure compliance with regulations. All of the inspection deficiencies have been entered in the facility maintenance log. Immediately following the complaint inspection all deficiencies identified with safety / tripping concerns were corrected, and signed off in the maintenance log. Many other deficiencies have been corrected and signed off by the maintenance staff. Items requiring repair or replacement, mattresses, furniture, etc., have been repaired or replaced. The remainder of the write-ups such as mini-blinds, ceiling blocks, etc. are awaiting parts and will be corrected when they are received. Any currently open deficiencies will be corrected by 15 July 2024 or as soon as the required parts are received.
Deficiency followed by correction date
12-4 Replaced floor tiles 6/3/24
Replaced overhead light cover
Replaced ceiling blocks 6/3/24
12-3 Repaired light switch area 5/10/24
Repaired door frame. No sharp edges 5/10/24
11-4 Replaced mini-blinds 6/3/24
10-1 Replaced dresser drawer 5/24/24
10-2 Replaced missing knob on dresser drawer 5/24/24
10-3 Replaced dresser drawer handle 6/20/24
Replaced ceiling blocks 6/20/24
10-4 Replaced ceiling blocks 6/20/24
Replaced floor tiles 5/28/24
10 K Cove base reattached and secure 5/28/24
Replaced ceiling blocks 6/20/24
9-1 Replaced floor tiles 5/22/24
Re-installed light cover 5/22/24
9 K Replaced floor tiles 5/23/24
9 LR Replaced floor tiles 5/23/24
Replaced ceiling tiles 6/22/24
Installed vent cover on AC unit 7/1/24
8-1 Replaced mini-blinds 6/14/24
Replaced window tiles 5/21/24
8-2 Replaced floor tiles 5/21/24
Replaced window screen 5/21/24
Replaced tiles under the bed 5/22/24
8-3 Replaced floor tiles 6/14/24
Replaced window tiles 6/4/24
Replaced missing vent cover 6/22/23
Replaced ceiling blocks 6/22/24
Repaired damaged door frame. No sharp edges 5/11/24
7-1 Reinstalled cove base 5/17/24
7-2 Reinstalled cove base 5/17/24
Secured cable wire 5/17/24
7-3 Installed properly fitted mini-blinds 5/22/24
7 K Replaced floor tiles 5/20/24
6-1 Repaired drywall 5/15/24
6-2 Replaced damaged chairs 5/15/24
6 K Repaired counter top and cabinet 5/15/24
5-2 Replaced outlet cover. No sharp edges 5/7/24
5-4 Replaced ceiling block 6/12/24
4-1 Replaced mini-blinds 5/10/24
4-3 Repaired door jamb and door frame. No sharp edges 5/13/24
4 K Repaired countertop 5/10/24
3 K Replaced floor tiles 5/10/24
2-3 Replaced dresser drawer 5/10/24
2-4 Replaced ceiling blocks 5/12/24
Replaced floor tiles 5/10/24
1-1 Repaired window frame 5/9/24
Replaced ceiling block 5/9/24
1-2 Replaced outlet cover. No sharp edges 5/8/24
1-3 Replaced floor tiles 5/9/24
1 K Replaced chair 5/9/24
E 4 Replaced floor tiles 6/6/24
Replaced torn chairs 6/6/24
Re-installed heater cover 6/6/24
Re-installed light cover 6/6/24
E 3 Replaced floor tiles 6/6/24
Replaced black chair 6/6/24
Installed a cover plate 5/7/24
E 2 Replaced mini-blinds 6/6/24
E 1 Replaced floor tiles 6/6/24
Reinstalled light cover 6/6/24
Severely stained carpet. Secured, no longer a tripping hazard. Carpeting will be replaced by 7/30/24 during upcoming remodel. Apt. will remain closed until remodel is complete.
E Hallway Repaired damaged floor and wall near recently repaired water lines. 6/25/24
2nd floor hallway - Replaced ceiling blocks 6/25/24
Emer. exit hallway - Repaired floor damage. No longer a tripping hazard. 5/8/24
1st floor hallway near exit doors - Repaired flooring and eliminated elevation change. Maintenance built up the floor in that area 6/25/24
Replaced missing floor tiles on stairwell landing 5/8/24
Reattached all step coverings. No longer a tripping hazard 5/8/24
Replaced ceiling tiles in 1st floor lounge 6/24/24
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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 conducted on May 7, 2024, the facility failed to maintain furnishing in a state of good repair in living rooms and lounges.
The following was observed during the physical plant inspection conducted on May 7, 2024:
Apartment 10 has living room furniture in disrepair. The light green chair has a cigarette burn on the arm and the lining was hanging down towards the floor.
Apartment 8 has a couch with torn material and it has cigarette burn, and the chair material is ripped.
Apartment 4 has a gray chair with multiple cigarette holes/burns and torn fabric.
Apartment 3 has a broken coffee table, the brown sofa had tears and the plaid chair was severely stained and has cigarette burns.
The first floor lounge has a torn black chair by the front desk.
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Plan of Correction
The Project Director will develop a facility maintenance plan, including developing an updated maintenance log, in order to report, track, and correct physical plant deficiencies. All facility areas, including lounges and living rooms, will be inspected weekly by the Project Director and/or his designated representative. All deficiencies will be documented in the facility maintenance log. Any deficiencies regarding safety issues will be corrected immediately upon discovery. Following each weekly facility inspection, the maintenance log will be updated, and new discrepancies will be reviewed by the Project Director and/or his representative and the maintenance staff. During this review any corrective actions taken by the maintenance staff between inspections will be discussed. The Project Director and/or his representative will perform a follow-up inspection on all corrective actions to ensure compliance with regulations. Any furniture in disrepair will be entered in the maintenance log and will be repaired or replaced by the facility maintenance staff as soon as possible. Regarding this complaint inspection, all identified damaged items of furniture have been replaced with clean, serviceable replacements. All of these deficiencies were entered in the maintenance log and signed off by the maintenance staff and a follow-up inspection to ensure compliance was performed by the Project Director or his designated representative.
Corrective actions were completed on 5/14 /2024. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on a physical plant inspection conducted on May 7, 2024, the facility failed to supply a bed with solid foundation and a fire retardant mattress in good repair.
The following was observed during the physical plant inspection:
In apartment 12, bedroom 2 has a severely stained and torn box spring.
In apartment 10, bedroom 1 has box spring edging coming off and sharp edges are exposed.
In apartment 9, bedroom 1 has an excessively stained box spring and bedroom 2 has a stained mattress.
In apartment 5, bedroom 1 has a mattress and box spring with multiple stains.
In apartment 1, bedroom 2 has a severely stained box spring.
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Plan of Correction
The Project Director will develop a facility maintenance plan, including an updated maintenance log, in order to report, track, and correct physical plant deficiencies. All facility areas, including mattresses, boxsprings, and bed frames, will be inspected weekly by the Project Director and/or his representative. All deficiencies will be entered in the facility maintenance log. Any discrepancies regarding safety issues will be corrected immediately upon discovery. Following each weekly facility inspection, the maintenance log will be updated and any new discrepancies will be reviewed by the Project Director and/or his representative and the maintenance staff. During this review any corrective actions taken by the maintenance staff during the prior week will be reviewed. The Project Director and/or his representative will perform a follow-up inspection on corrective actions taken by the maintenance staff during the prior week to ensure compliance with regulations.
All mattresses and boxsprings identified during the complaint inspection were entered in the maintenance log as unserviceable and they were removed and replaced immediately following the complaint inspection, due to safety issues such as sharp edges and severe stains, and signed off by the maintenance staff. The Project Director or and/or his representative have performed a follow-up to ensure compliance on 8 May 2024. |
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 conducted on May 7, 2024, the facility failed to ventilate the toilet and wash rooms by exhaust fan or window.
The following was observed during the physical plant inspection:
Efficiency apartment 4
Bathroom has no mechanical ventilation system and the window is not operable.
Efficiency apartment 3
Bathroom has no mechanical ventilation system and the window is unable to be reached.
Efficiency apartment 2
Bathroom has no mechanical ventilation system and the window is unable to be reached.
Efficiency apartment 1
Bathroom has no mechanical ventilation system and the window is unable to be reached.
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Plan of Correction
The Project Director consulted with the facility maintenance staff supervisor to determine a course of action to correct this deficiency. The maintenance staff supervisor developed an adjustment rod in order to manually operate (open and close) the window from the floor. These adjustment rods have been installed in efficiency bathrooms 1,2,and 3.
The Project Director performed an operational check on efficiency bathroom windows 1,2, and 3 and found that all of three bathroom windows are easy to use and are fully operable from the floor.
Efficiency 4 is awaiting maintenance to schedule repair (awaiting parts). This deficiency will be corrected fully by 7/19/24.
This apartment will remain closed until ventilation window is fixed. Estimated completion date -7/19/24. |
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 conducted on May 7, 2024, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The following was observed during the physical plant inspection:
Apartment 12:
Bathroom has cracked tile and the bathtub has a black mold like substance in the corner and broken slots in the bathroom miniblind and loose towel rack.
Apartment 10
Bathroom floor appears to be unsturdy and uneven. When walked on, the floor has areas that sink and do not feel supported by a plywood underlayment.
Apartment 9
Bathroom has broken floor tiles and the vanity doors do not close.
Apartment 8
Bathroom sink has multiple cracks.
Apartment 7
Bathroom has black mold like substance in the corners of the bathtub and the vanity door does not close.
Apartment 5
Bathroom bathtub has an excessive amount of soap scum and broken ceiling tile.
Apartment 2
Bathroom vanity is missing a drawer.
Efficiency apartment 4
Bathroom has cracked tiles
Efficiency apartment 3
Bathroom has black mold like substance around edge and cracked tile around soap dish in the bathtub.
Efficiency apartment 2
Bathroom has a bathtub with missing tiles.
Efficiency apartment 1
Bathroom has a large crack in the vanity countertop, the hot and cold-water facet knobs are missing in the bathtub.
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Plan of Correction
The Project Director will develop a facility maintenance plan, including developing a maintenance log, in order to report, track, and correct physical plant deficiencies. All facility areas including all facility bathrooms, will be inspected weekly by the Project Director and/or his designated representative. All deficiencies will be documented in the facility maintenance log. Any deficiencies regarding safety issues will be corrected immediately upon discovery. Following each weekly facility inspection, the maintenance log will be updated and new discrepancies will be reviewed by the Project Director and/or his representative and the maintenance staff. During this review any corrective actions taken by the maintenance staff during the prior week will be reviewed. The Project Director and/or his representative will perform follow-up inspections on all corrective actions to ensure compliance with regulations.
All discrepancies cited in this complaint investigation were entered in the maintenance log. Many of these write-ups cited during the complaint inspection have been corrected. All discrepancies regarding "mold-like" mildew have been scrubbed clean and resealed. Any write-ups signed off as corrected have been inspected by the Project Director and/or his representative. In apartment #10 cited for unsteady bathroom floor, repair is in progress. We relocated the clients who have been living there and shut down Apartment #10 for remodel which includes replacing the entire floor structure as well as many minor discrepancies. All minor/cosmetic write-ups remaining are awaiting parts. These remaining write-ups have parts on order and will be corrected by 7/15/2024. Apartment #10 remodel including replacing the bathroom floor replacement has an estimated completion of 7/30/2024. |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a physical plant inspection conducted on May 7, 2024, the facility failed to be free of a rodent infestation. Per the facility's Pest Control Policies and Procedures, a contracted pest control company is to perform monthly inspections and treat necessary areas. The facility is to call the pest control company immediately if there is an infestation.
Documentation of monthly inspections was missing for February 2024 and April 2024. Per staff and client interviews mice have been seen in the facility as recently as last week. Numerous mouse traps were observed during the physical plant inspection conducted during the complaint investigation.
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Plan of Correction
The Project Director is responsible for ensuring that the facility pest control policy is enforced. The facility has had a written agreement, since 4/20/19, with JOY Pest Control to provide services and monthly inspections. In order to ensure compliance with this agreement the Project Director and JOY Pest Control will meet no later than 7/15/2024 to arrange a schedule for the remainder of the year of hard dates when we will expect services. This schedule will be renegotiated at the beginning of each calendar year. Services include filling bait boxes and inspecting areas where mice have been observed as well as inspecting all areas of the facility for insect infestation. Facility support staff also place mouse traps in some apartments where mice have been observed in the past. The Project Director will be responsible ensuring the pest control policy is adhered to as well as ensuring that pest control inspections occur on the dates agreed to by the Project Director and JOY Pest Control. The schedule of visits will be kept in the business office and shared with the support staff supervisor who will back-up the Project Director to ensure compliance. |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on a physical plant inspection conducted on May 7, 2024, the facility failed to limit smoking to designated smoking areas.
During the physical plant inspection, the following was observed:
In apartment 8, Bedroom 1, a cigarette butt was observed inside a plastic bottle and ashes were on the floor and it smelled like cigarette smoke.
In apartment 6, Bedroom 2 smelled like cigarette smoke and cigarette butts were observed on the windowsill.
In apartment 2, Bedroom 4 smelled like cigarette smoke.
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Plan of Correction
The Project Director is responsible for ensuring smoking is limited to designated smoking areas. The facility has a large semi-covered area in the rear of the facility this is the designated smoking area. There is no smoking allowed inside the facility. For the most part, clients accept and abide by this policy. For those clients who have trouble following this policy, we have relied on apartment/room inspections and report by other clients/roommates. In order to get a better source of information on goings on in the apartments, the Project Director and the support staff supervisor have assigned blocks of three apartments each to one dayshift and one second shift support staff members. This means there are two staff members on two different shifts monitoring a block of three apartments. These staff members will be responsible for visiting each of their assigned apartments at least once a day. The idea is that we will not only learn which clients may be smoking, but we will have much more information on roommate relationships, who is not doing his fair share of cleaning, who is taking other room mates food etc. The clients in 8-1, 6-2, and 2-4 received a verbal warning as a first offense. Our policy on clients smoking inside are first offense verbal warning, second offense written warning, third offense behavioral contract / case consultation, fourth offense possible discharge. Because we are starting this apartment monitoring policy as of 7/1/2024 we can expect it to be fully implemented by 7/15/2024. The Project Director and the staff support supervisor will be responsible for implementing and oversight of this policy. |