INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted June 26-27, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Clem-Mar House Inc. 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 on June 26, 2024, the facility failed to keep the building and its grounds in good repair at all times for the safety and well-being of residents, employees and visitors.
The two wooden picnic tables in the patio smoking area were observed to be broken with pieces of wood missing and sharp wooden edges exposed on the table. In addition, one of the benches attached to the picnic table was missing a portion of the seat/wooden board.
Client bedroom #2 has a doorknob attached to the door by two pieces of wood with exposed sharp edges.
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Plan of Correction
Support staff, including maintenance staff, within the facility will work to repair the picnic tables. The tables will also be painted, and this will be completed by Monday 07/15/2024.
Room 2's doorknob was fixed on 07/07/2024.
During regular, weekly facility inspections the Project Director or designated representatives shall ensure that the Clem-Mar House maintains continued compliance with Chapter 705 Physical Plant.
If any safety discrepancies are noted, the Project Director will work the facility staff, or outside agencies, to immediately repair any documented issues within a timely manner. |
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 June 26, 2024, the facility failed to maintain furnishing in a state of good repair in living rooms and lounges.
The TV room/lounge has two couches with ripped and torn fabric. The decorative pillows on both couches also have rips and tears.
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Plan of Correction
Ripped and torn pillows were discarded on 07/07/2024. Couches will be repaired by Monday 07/15/2024 with adhesive fabric repair.
During regular, weekly facility inspections the Project Director or designated representatives shall ensure that the Clem-Mar House maintains continued compliance with Chapter 705 Physical Plant, including the inspection of all furniture.
If any safety discrepancies are noted, the Project Director will work the facility staff, or outside agencies, to immediately repair any documented issues within a timely manner. |
705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on a physical plant inspection conducted on June 26, 2024, the facility failed to maintain counseling areas with furnishings which are in good repair.
The Intake Counselor's office, the Lead Counselor's office, and other Counselor's offices were observed to have worn out and torn chairs.
The Great Room which is used for group counseling, meals, and meetings was observed to have at least four chairs that were ripped and torn.
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Plan of Correction
Ripped and torn chairs were repaired and discarded on 07/07/2024.
During regular, weekly facility inspections, the Project Director or designated representatives shall ensure that the Clem-Mar House maintains continued compliance with Chapter 705 Physical Plant, including the inspection of all furniture in common areas and offices.
If any safety discrepancies are noted, the Project Director will work the facility staff, or outside agencies, to immediately repair any documented issues within a timely manner. |
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 June 26, 2024, the facility failed to maintain each bathroom in a funcational, clean, and sanitary manner at all times.
The large bathroom on the 2nd floor has a black mold-like substance around the bathtub and a cracked sink and vanity.
The small bathroom on the 2nd floor has rust around the tub, a rusty metal shower caddy hanging over the shower head, and a cracked sink and vanity.
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Plan of Correction
On 07/07/2024 discolored caulking was removed and replaced. Rust and hardwater stains were cleaned and removed. The metal caddy was removed and replaced.
Both sinks and vanities will be repaired by 07/15/2024.
During regular, weekly facility inspections, the Project Director or designated representatives shall ensure that the Clem-Mar House maintains continued compliance with Chapter 705 Physical Plant, including the inspection of bathrooms.
If any safety discrepancies are noted, the Project Director will work the facility staff, or outside agencies, to immediately repair any documented issues within a timely manner. |