INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 21, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection The Behavioral Wellness Center at Girard Return 1 & 2, 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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705.6 (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 September 21, 2023, between 9:30 AM and 12:30 PM, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times. The following bathrooms were found to not be functional, clean, or sanitary at the time of the inspection:-Bathroom in room 1007, 1008, 1005, 1004, 1002, 902, 903, 907, 908 had the appearance of mold.-Bathroom in room 1007 had broken tiles.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will been retrained and disciplined for strict adherence to cleaning protocols with proper chemicals and tools. Follow up includes make sure that staff understand the importance of cleaning the showers properly and that they have the knowledge and skills necessary to do so.
-All shower caulking will be removed followed by applying new caulking
EVS supervisor will conduct weekly rounds on all unit showers and by tracking the satisfaction rates among patients and staff. This will be monitored for two months for 100% compliance |
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 on a physical plant inspection conducted on September 21, 2023, between 9:30 AM and 12:30 PM, the facility failed to ensure that all heaters were permanently mounted or installed as there was a space heater located on 11th floor behind the nurse ' s station.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1.Clinical Supervisors will conduct search of each residential program for heaters. If a heater(s) is found the item will be removed from facility.
a. Responsible party ? Residential Clinical Supervisors
b. Completion date 9-25-23
2. Clinical Supervisors will inform employees that free standing heaters are not permit in the facility, during next staff meeting.
c. Responsible party ? Residential Clinical Supervisors
d. Completion date 9-25-23
3. Clinical Supervisors will survey their assigned program to determine, if there a need for permanently mounted or installed as a space heater in a certain area
a. Responsible party ? Residential Clinical Supervisors
b. Completion date 9-25-23
4. Clinical Supervisors will create a work order(s) to install permanently mounted space heater in an area(s) identified as needing heat and forward to operations.
a. Responsible party ? Residential Clinical Supervisors/VP Operation
b. Completion date 9-25-23
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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 September 21, 2023, between 9:30 AM and 12:30 PM, the facility failed to limit smoking to designated smoking areas. There were cigarette ashes in the bathroom of the 11th floor room 3.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1.Clinical Supervisors will enforce Policy :730.606 Tobacco Free Policy
a Responsible party ? Residential Clinical Supervisors and Support Staff (Addiction Recovery Assistant)
b. Completion date 9-25-23
2.Nursing will provide participants with Nicotine Replacement Therapy (NRT) as needed.
a Responsible party ? Nursing
b. Completion date 9-25-23
3.Support staff will monitor participants ability to abide by Policy :730.606 Tobacco Free Policy
a Responsible party ? Residential
Clinical Supervisors and Support Staff (Addiction Recovery Assistant)
b. Completion date 9-25-23
4.Support staff will perform safety search of the participants and his/her belongings for contraband, Policy y :730.413 Contraband and Policy: 730.412
a Responsible party ? Residential Clinical Supervisors and Support Staff (Addiction Recovery Assistant)
b. Completion date 9-25-23
5.Staff will escort and monitor participants in designated outside smoking areas.
a Responsible party ? Residential Clinical Supervisors and Support Staff (Addiction Recovery Assistant)
b. Completion date 9-25-23
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