INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 14, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Nanticoke Medical Center 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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705.22 (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 always keep the grounds in good repair as the porch outside of the group room is damaged and presents as a trip hazard. In addition, the wall unit that secures the fire extinguisher closest to the reception area is broken and hanging off the wall by one hinge.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The porch area which is normally closed,THere was a wood floor plank damaged. We had the floor plank replaced.
Maintenane person will inspect all exterior flooring on a weekly basis. Any deficiency will be corrected by maintenance employee.
Fire extinguisher cabinet was recently painted, with door closed and had become stuck on trying to open had damaged the hinge.
door to fire extinguisher cabinet hinge was replaced.
Maintenance individual will inspect this on a weekly basis and correct any issues that may arise. In addition Director will inspect on a monthly basis. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to have hot and cold water under pressure as the facility does not currently have running water.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
There was a repair in process to the water main and was completed. This will be checked by maintenance individual on a daily basis and addressed immediately if any issues arise. |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential 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 as the bathroom was not clean at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All restrooms were cleaned and sanitized.
There will be a logbook placed in each restroom indicating the custodial individual cleaning and signing the book. will be done every 4 hours.
Will be the responsibility of custodial individual. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility is not permitted to have heaters that are not permanently mounted or installed however, a portable heater was observed in the project director's offices.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The heater was immediately removed, there will never be any portable heater permitted in building again. Custodial staff will inspect during their cleaning end of each day and remove any such object immediately. Custodial staff will be responsible. |
705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all fire extinguishers were securely mounted to the wall as the fire extinguisher located in the middle of the facility was on the floor.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
When the vendor updated the inspections for the fire extinguishers. Extinguishers were not set back in their places properly. This was corrected and mounted properly back onto the wall. The maintenance individual will be responsible for inspecting on a weekly basis and addressing immediately if any deficiencies. |