INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 28, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, ADAPPT House, was found to be not 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 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
The facility failed to ensure that the exterior grounds were maintained and free from danger to health and safety.*The sidewalk in front of the building along Madison Avenue where the secure entrance is located is cracked and broken which created a trip hazard.
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Plan of Correction
The facility is currently in the process of soliciting bids to repair the sidewalk. Bids are due by May 13, 2019. Once a contractor has been selected, repairs of the sidewalk will immediately begin. Estimated date of completion is June 7, 2019 |
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 that the facility was free from danger to health and safety of clients, staff and visitors.*The carpeted mat, at the secure entrance in front of the metal detector, had been taped down but the tape was missing at the corners and the mat was curling up at the edge which created a trip hazard. *The carpet in bedrooms #3 & 4 was worn through and damaged which created a tripping hazard.*There was a water spigot protruding into the path of egress, on the exterior stairs from the wall at the exterior exit stairs, from the men's wing to the parking lot near Madison Avenue.*The exterior stairs from the women's wing to the parking area had a broken tread and several loose treads which created a safety hazard.This was discussed with facility staff in order to eliminate the dangerous conditions.
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Plan of Correction
On April 8, 2019 The secure entrance floor mat was replaced.
Bids to replace all flooring, including rugs, throughout the "alcohol " and other drug unit have been received and are currently being reviewed for and award. Flooring replacement will begin immediately upon award. Estimated date of completion is July 31, 2019
A plumbing contractor will be onsite April 26, 2019, to recess the water spigot into the wall.
On March 28, 2019, repair of broken and loose stairs treads on the women's wing exteriors stairs was completed.
Moving forward daily inspections will take place to ensure the safety conditions of the facility and report and maintain repairs as needed to all area |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
The facility failed to store trash, garbage and rubbish in covered containers. Three dumpsters in the parking area next to the facility were not covered and did not have functional lids.
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Plan of Correction
On April 8, 2019, the three identified trash dumpsters were replaced with new dumpster with functioning lids
Moving forward there will be an ongoing facility wide monitoring to support daily inspections by monitoring staff to take place to ensure the safety and sanitary conditions of the facility and repairs needed to all storage trash containers
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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
The facility failed to maintain furnishings in good repair.*The couch in the male lounge had cushions that were torn and part of the wood frame had broken creating a sharp, splintered edge.
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Plan of Correction
On April 8, 2019, the damaged couch located in the male lounge was replaced.
Daily inspection by monitoring staff will take place to ensure that the furnishings is in good conditions. Repairs will be reported to clinical supervisor and maintenance so repair can be done accordingly.
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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
The facility failed to ensure that bathrooms were maintained in a functional, clean and sanitary manner.In the female bathroom the latch had been removed and replaced with a long bolt that protruded out and had a sharp end which created a safety hazard.Additionally, the toilet in the stall nearest to the door was clogged.
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Plan of Correction
On March 28, 2019, the clogged toilet was repaired.
Prior to May 3, 2019, the facility director will inspect all latches in the facility restrooms. Latches that do not function properly, or are a safety hazard, will be replaced. Additionally, prior to May 6, 2019, inspection of restroom areas will be incorporated into the daily inspection process to ensure each toilet is operational and there are no safety hazards present. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's fire drill record, from January 2019 through March 2019, the facility failed to indicate which exite route was used.
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Plan of Correction
On April 23, 2019, the facility director provided instruction to the assistant director of operations, assistant director of programs, and shift supervisors regarding the requirement to document exit routes utilized during fires drill. On April 24, 2019, a fire drill was conducted and reviewed by the facility director to confirm that exit routes were documented as required.
Daily inspections by the Assistant Facility Director to ensure fire drills are being documented and all exit routes are being utilized during firer drills |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on interviews with staff and clients on 3/28/19, the facility failed to prepare alternate exite routes to be used during fire drills. During the interviews staff and clients stated that the only exit utilized during fire drills was the main entrance that deploys to Madison Avenue.
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Plan of Correction
On April 23, 2019, the facility director provided instruction to the assistant director of operations, assistant director of programs, and shift supervisors regarding the requirement to document alternate exits routes utilized during fire drills. On April 24, a fire drill was conducted and reviewed by facility director to confirm that exit routes other than the main enter were utilized.
On April 23, 2019 two different fire exit routes were used.
On April 23, 2019 The Assistant facility Director has directed all monitoring staff to utilize all fire exit routes. Weekly inspection by Assistant Facility Director will take place to ensure fire drills are being documented and all exit routs are being utilized |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to protect the confidentiality of client identity.The door leading to the outside area, adjacent to the neighbors rear yard, had a large window which allowed direct visual access into the facility; this area is accessible to clients and is a passage to client bedrooms and the medication area.
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Plan of Correction
On April 23, 2019, the door leading to the outside area was frosted to provide privacy and preserve the confidentiality of each client's identity
Moving forward on going facility wide monitoring security staff and clinical supervisor to ensure that all windows are frosted so to protect the confidentiality of client's identity |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on staff and client interviews on March 28, 2019, the facility failed to report an incident that occured on 3/3/19, which required the presence of ambulance personnel.
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Plan of Correction
On April 23, 2019, the facility director reviewed the Department of Drug and Alcohol Prevention's policy requirements for reporting unusual incidents involving the presence of police, fire, and ambulance personnel with the assistant director of programs, assistant director of operations, and facility shift supervisors. Going forward, the appropriate assistant director will review unusual incident reports daily and will submit the reports to the department within three business days as required. Additionally, the facility director will be notified and copied on each report submitted. |