INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on September 4, 2019 by staff from the Department of Drug and Alcohol Programs. 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 investigation.
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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
The facility failed to ensure the safety of staff and clients, as this was observed during a physical plant inspection. The stairwell leading to the basement had several loose steps, as well as ripped carpet, which created a tripping hazard.The deficiency was discussed with facility staff in order to eliminate the dangerous condition.
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Plan of Correction
The Project Director will ensure that the building maintenance team repairs and/or replaces all loose steps and removes and replaces all damaged carpeting. These repairs will bee completed no later than 30 September 2019. Until repairs are completed, a barrier will be placed in front of the stairwell and its use will be restricted to building maintenance team members, only. |
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
The facility failed to limit smoking to designated smoking areas as observed during the physical plant inspection and interviews conducted on September 4, 2019. Based on interviews with staff and residents, it was unclear what the facility's policies were regarding the designated smoking areas and where smoking was not permitted.This deficiency was discussed with facility staff in order to eliminate the dangerous condition.
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Plan of Correction
The Project Director will establish a mandatory facility smoking policy no later than 30 September 2019. Smoking will be restricted to a designated smoking area in the rear of the building.
All current clients will be notified of our updated smoking policy by the Clinical Supervisor no later than 30 September 2019. New clients will be notified by the intake coordinator at intake and will sign a document stating that they understand and will abide by this policy. This document will be entered into the consent section of the client's chart. As of 30 September 2019, clients found to be in violation of this policy will be reprimanded, this violation will be documented and entered into the client's chart. Any further violations may result in penalties up to and including involuntary discharge.
All current staff will be notified of our smoking policy by the Clinical Supervisor no later than 30 September 2019. all new staff members will be notified of our smoking policy by the Clinical Supervisor prior to employment. Any violation of this policy will result in reprimand, which will be entered in the employee's personnel file. Any additional violations will result in actions up to and including termination.
the Project Director and managerial staff members will perform random inspections of all areas including client's bedrooms for evidence of smoking to ensure that clients and staff members abide by this policy.
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705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
The facility failed to ensure that the stairwell leading to the basement was properly illuminated at all times, based on a physical plant inspection conducted on September 4, 2019.Due to the safety concerns, this information was shared with facility staff.
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Plan of Correction
The Project Director will ensure that the building maintenance team repairs the lighting system in the basement stairwell. These repairs will be completed, and an operational check of the lighting system will be accomplished, no later than 30 September 2019. Until the repairs are completed, a barrier will be placed in front of the basement stairwell, and access will be restricted to building maintenance team members only. |