INITIAL COMMENTS
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This report is a result of findings during and on-site physical plant inspection conducted on April 19, 2013 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, 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. The following deficiencies were identified during this inspection:
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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 upon the physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times. The findings include:The physical plant inspection was conducted on April 19, 2013, from approximately 9:15 AM to 1:00 PM. The facility failed to keep the grounds of the facility and adjacent yard, clean, safe and sanitary. While the adjacent yard is not part of the facility, the building owner confirmed that he owned both properties and that clients had access to the yard for recreational purposes. The following items were observed just outside the rear door of the facility:- a torn, empty soda box was situated on the back steps leading to the basement- candy wrappers and other pieces of paper were on the ground- a loose cinder block was on the walkway- a black bucket was on the walkwayThe following items were observed in and/or around the adjacent yard:- a child's electric 4-wheeler- a wooden pallet was leaning against a wall- a wooden ladder was leaning against a wall- a metal ladder was situated on the ground- a red, 5 gallon gas can- two bench seats and other pieces of furniture- uncut weeds and vines were along the edges and wallsIn addition, the facility failed to keep the grounds of the facility safe as a one gallon, red plastic fuel container was being stored next to the furnace in apartment # 5. The container had approximately an eighth to a quarter inch of flammable liquid inside at the time of inspection.The findings were confirmed by the property owner during the inspection.
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Plan of Correction
The rear of the building and the adjacent yard have been cleared of all trash and debris. Weekly inspections by a Manager will ensure that trash does not accumulate in the future.
The red plastic fuel container has been removed and all clients have been told that no highly flammable substances are allowed in the building. Weekly inspections by Managers of the apartments will ensure that no highly flammable materials are brought into the facility.
The Project Coordinator and Building Maintenance Director will be responsible for making sure the premises is free of debris and dangerous substances. |
705.5 (i) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(i) Each bedroom shall have a window with a source of natural light.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that each bedroom shall have a window with a source of natural light in one of four bedrooms in apartment # 5.The findings include:The physical plant inspection was conducted on April 19, 2013, from approximately 9:15 AM to 1:00 PM. As per the building owner, the source of natural light for several of the facility's interior bedrooms, including bedroom # 5-3, was an open air light well that extended from the second floor to the roof. At the time of inspection, the window in bedroom # 5-3 was painted over; therefore, no natural light was available for the bedroom.The Project Coordinator confirmed the findings during the inspection.
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Plan of Correction
The paint has been removed from the window in bedroom 5-3. The Project Coordinator and Building Maintenance Director will ensure that no windows are permanently covered in any of the apartments. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit in one of five bathrooms on the third floor.The findings include:The physical plant inspection was conducted on April 19, 2013, from approximately 9:15 AM to 1:00 PM. The hot water in the bathroom located in apartment # 12 was too hot for the Licensing Specialist to keep a hand under it. However, the water in the hot water heater tank was drained before the Licensing Specialist was able to obtain its temperature. However, the property owner stated that both the upper and lower thermostats in apartment 12's hot water heater were set at 130 degrees Fahrenheit at the time the Licensing Specialist turned on the hot water. The building owner did not dispute the findings.
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Plan of Correction
The hot water heater has been turned down and the temperature of the water is now below 120 degrees. The Building Maintenance Director will check water temperatures each month to ensure that the water temperatures in the apartments do not exceed 120 degrees. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that heaters that are not permanently mounted or installed are not permitted inside the facility.The findings include:The physical plant inspection was conducted on April 19, 2013, from approximately 9:15 AM to 1:00 PM. A portable heater was found in bedroom # 5-3.The findings were confirmed by the Project Coordinator during the inspection.
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Plan of Correction
The portable heater has been removed and all clients have been told that electric heaters are not allowed on the premises. Weekly inspections by Managers of the apartments will ensure that there will be no portable heaters in the apartments. The Project Coordinator will be responsible for ensuring that these inspections take place and that no portable heaters are in the facility. |
705.10 (a) (1) (iv) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based upon the physical plant inspection, the facility failed to clearly indicate exits by the use of signs in the basement and on the first floor.The findings include:The physical plant inspection was conducted on April 19, 2013, from approximately 9:15 AM to 1:00 PM. The basement had two exits that included a set of steps that were located inside the facility and a door that opened to an external set of steps in the rear of the building. The facility failed to clearly indicate the rear exit from the basement by the use of a sign. In addition, the facility failed to clearly indicate a second means of egress from the first floor day room and the first floor apartment. The findings were reviewed with the Program Coordinator and the building owner during the exit interview.
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Plan of Correction
In the basement an exit sign has been placed over the rear door. On the first floor exit signs have been place over the door leading to the back half of the building. The window on the first floor will not be designated as an exit. The Building Maintenance Director will be responsible for ensuring that all exits are properly marked. |
705.10 (b) (2) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(2) On floors with resident bedrooms, maintain a smoke detector which shall be located within 15 feet of each bedroom door. On floors with no resident bedrooms, the smoke detection device shall be located in a common area or hallway. All detection devices shall be interconnected.
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Observations
Based upon the physical plant inspection, the facility failed to maintain a smoke detector within 15 feet of each bedroom for 11 of 17 bedrooms on the second floor and 11 of 18 bedrooms on the third floor.The findings include:The physical plant inspection was conducted on April 19, 2013, from approximately 9:15 AM to 1:00 PM. The facility contained eleven apartments that are spread across three floors. The first floor had one apartment with four bedrooms, the second floor had five apartments that contained seventeen bedrooms and the third floor had five apartments that contained eighteen apartments. The facility maintained smoke detectors in the common hallways on all three floors, which were within 15 feet of some of the front bedrooms. In addition, each apartment had a smoke detector located in the kitchen area that was within 15 feet of the middle and rear bedrooms. However, the smoke detectors contained in the apartments located on both the second and third floors of the facility were not operational at the time of inspection. Therefore, the facility failed to maintain a smoke detector within 15 feet of the following bedrooms:Second floor bedrooms #: 3-1, 3-2, 3-3, 4-2, 4-3, 5-3, 5-4, 6-3, 6-4, 7-2 and 7-3.Third floor bedrooms #: 8-1, 8-2, 8-3, 9-2, 9-3, 10-3, 10-4, 11-3, 11-4, 12-3 and 12-4.The Project Coordinator and the building owner confirmed the findings during the inspection.
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Plan of Correction
The interconnected smoke detector/fire alarm system located in the hallways and kitchens of the facility has been fixed and is now working properly. In addition the individual battery operated smoke detectors located in the bedrooms have had their batteries replaced and are now working properly as well. The Project Coordinator will be responsible for ensuring that all smoke detectors and fire alarms are in working order during the monthly fire drill. This will be documented in the fire drill log under the "System Status". |
705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential 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, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based upon the physical plant inspection, the facility failed to maintain a portable fire extinguisher in the basement with a minimum of an ABC rating.The findings include:The physical plant inspection was conducted on April 19, 2013, from approximately 9:15 AM to 1:00 PM. There were no fire extinguishers located in the basement, which contained an electrical panel, hot water heater and furnace that serviced the first floor of the facility. The findings were confirmed by the Project Coordinator during the inspection. The Project Coordinator stated that the basement encompassed between 2000 and 3500 square feet. Therefore, the facility was required to maintain at least two ABC rated fire extinguishers in the basement.
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Plan of Correction
We have contacted the fire extinguisher company and have ordered two additional fire extinguishers. They will be installed in the basement by May 3. The Building Maintenance Director will be responsible for ensuring that all areas of the facility have the appropriate number of fire extinguishers. |