INITIAL COMMENTS
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This report is a result of an onsite complaint investigation conducted on September 18, 2020, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the investigation, Pocono Mountain Recovery Center, 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 and a plan of correction is required.
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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 maintain all structures, fences and playground equipment to be free from danger to health and safety.A physical plant inspection was conducted on September 18, 2020 which revealed wooden furniture that was in disrepair, with broken and exposed wood, and exposed screws which created a safety hazard.
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Plan of Correction
Maintenance Department will remove all disrepair furniture by 10/30/20 and will be replaced. Monthly environmental walkthroughs will take place to ensure the furniture is safe and if any repairs need to be completed. |
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 maintain the grounds of the facility in good repair for the safety of residents, employees and visitors. A physical plant inspection was conducted on September 18, 2020 which revealed the following deficiencies:stone foundation in the boiler room is deteriorating which is causing the floor to sag in the nursing area and creating structural instability. block wall in the stairwell to the boiler room is heaving and in disrepair. is a water outlet flange that protrudes out into the second step from the bottom of the landing to the boiler room, which creates a trip hazard.flagstone steps from parking area to the main sidewalk are not aligned with concrete which creates a trip hazard. " acute room " in the back of the detox nursing station had two partially full sharps containers which were accessible to anyone in the room. threshold from the hallway to the nursing area was missing creating a trip hazard.threshold from the outside walkway to the main hall where the AA room and nursing area are located had carpet that was torn, creating a trip hazard.loading platform area behind the kitchen is elevated 60 " from the parking lot. The gates that close off the end of the loading dock were left open and were blocked form closing by mop buckets, chairs, empty milk crates, a large cart laying on its side and a trash can; this created a fall hazard.was a large broken section of the edge of the sidewalk coming from the main building down to the walkway adjacent to the residential area. concrete patio area outside the detox and nursing area was damaged. were building materials and scraps of siding laying on the ground as well as an unattended ladder deployed next to the laundry building. was a tree stump in the path from the main building to steps leading to the upper level recreation area.
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Plan of Correction
Director of Maintenance will continue to solicit contractors to bid on the foundation work. We will select a contractor and notify DDAP by 12/1/2020. Within 15 days of the selection of a contractor, we will provide DDAP with the written work agreement. Upon commencement of the work we will Provide DDAP with updates every two weeks until the job is finished. Work will be completed by 2/1/2021.
Supervisor of Facility Ops painted the water flange yellow for noticeability and trip hazard on 9/18/2020. Periodic checks will be conducted monthly to ensure the paint is not chipping off or if it will need to be re-painted.
Maintenance will fill all cracks and broken flagstone will be filled in with cement creating a smooth surface to be completed by 10/30/2020. Monthly checks will be conducted during the environmental walkthrough to ensure cement is holding.
All Sharpe's containers were removed on 9/18/2020 and were placed in a biohazard box and locked in a secured area of the nursing department. Going forward all sharps containers will continue to be locked in a secure area of nursing and placed in a bio-hazard box until time of pick-up.
Maintenance Department will re-secure carpet. To be completed by 10/30/2020.
Supervisor of Facility Ops and Risk Management Assistant will continue to inspect all thresholds during monthly inspections.
All obstructions will be moved and sign that states "PLEASE KEEP CLOSED" will be put onto the loading dock gate by 10/30/2020. Discussed with proper staff member, daily monitoring will take place by the Manager of Food and Nutrient.
Maintenance department has contacted several contractors and presently receiving estimates for repairs. Will be completed by 12/30/2020. A cone will be placed by broken sidewalk to ensure no person walks through it. Monthly environmental walkthroughs will be conducted to ensure the repairs are still intact. Repairs will take place as needed.
All building materials that contactors have left will be removed by 10/30/2020. If there is, more construction that needs to be done all materials will be kept in one place, closed off to patients and staff members ensuring safety.
Maintenance department has partially removed tree stump as of 9/18/2020. Facility was waiting for a tool arrival to finish removal. Will be completed by 10/30/2020. Monthly environmental walkthroughs will be conducted to be on the look for more tree stumps that may need to be removed.
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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 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.Upon arriving at the facility on September 18, 2020, it was noted by DDAP staff that the dumpster was overflowing with trash and the lid and side door were not able to be closed. Additionally, there was trash and other refuse strewn about in the area adjacent to the dumpster.
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Plan of Correction
A new dumpster will be put in place near the laundry room, to be onsite and operable by 11/01/2020 to ensure no over flow of garbage. The Manager of Food and Nutrient will monitor the dumpster daily. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
The facility failed to ensure that exits from the facility were unobstructed.loading platform behind the kitchen is an emergency exit path from the second floor, with a ladder affixed to the wall leading down to this area. This area was cluttered with mop buckets, chairs, empty milk crates, a large upended cart and a trash can.
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Plan of Correction
All obstructions will be moved and sign that states "PLEASE KEEP CLOSED" will be put onto the loading dock gate by 10/30/20. Discussed with proper staff member, daily monitoring will take place by the Manager of Food and Nutrient. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
The facility failed to maintain outside steps with a well secured handrail. 6-step concrete staircase behind the main building does not have a handrail.
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Plan of Correction
Maintenance Department will be removing these steps by 10/22/20. Caution tape will be placed around the steps before the repairs take place to ensure the safety of our patients and staff. Monthly walkthroughs will be completed to look over the area of the removed steps to ensure no obstructions are created. |
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
The facility failed to report the presence of an ambulance onsite.On March 3, 2020 an employee required transport to the emergency room following a reaction to an insecticide powder. Transportation was via ambulance which was confirmed with the facility staff, however no unusual incident report was submitted to the Department.
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Plan of Correction
Clinical Director and Risk Management Assistant met and reviewed on 10/14/20 review regulations on time accuracy of filing out form. All reportable incidents will be reported. Reviewing of all unusual incidents will be reviewed at the monthly safety meeting. |