INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 8-9, 2022 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, The Retreat at White Birch Outpatient was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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, it was observed that the facility failed to ensure the safety and well-being of clients, staff and visitors.
The office this DDAP staff person was placed in was missing two electrical outlet covers. In addition, the ceiling in this office had peeling paint in two places.
These findings were reviewed with facility staff during the investigation.
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Plan of Correction
The office that the DDAP staff person was placed in had two electrical outlet covers missing and some of the popcorn finish on the ceiling was peeling.
To correct this deficiency a work order was placed with the landlord of the office to replace the outlet covers and repair the ceiling on 03/23/2022. The repairs were made on 03/29/2022.
To prevent the reoccurrence of this deficiency, The Executive Director and the Quality Assurance Coordinator at The Outpatient Facility will inspect the physical plant weekly for any repairs that need to be made and see that the repairs are made in a timely manner.
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