INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 25, 2016, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc., Vantage House 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:
|
Plan of Correction
|
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
Based on the onsite inspection of the physical plant conducted on May 25, 2016, the facilty failed to ensure that the hot water in all of the bathrooms did not exceed a temperature of 120 degrees Fahrenheit.
The hot water temperature for the bathroom in the handicapped bedroom was tested at 125.0 degrees Fahrenheit.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
As per licensing regulations 705.6 the hot may not exceed 120 Fahrenheit.
In order to correct this deficiency the Physical Plant Manager for the Central Region is scheduled to correct the temperature of the hot water in our handicap bedroom on July 8th, 2016.
In order to ensure that this deficiency does not recur, the Program Director will monitor the temperature of the water on a bi-monthly basis. This monitoring will begin on September 8th 2016. |
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.
|
Observations
Based on a review of facility documents conducted on May 25, 2016, the facility failed to prepare alternate exits routes during fire drills.
The fire drill logs from July 13, 2015, through May 19, 2016, document that the facility used all of the facility exits for every fire drill conducted during that time period.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
As per licensing regulation 705.10 (d) (1)-(9) Fire drills must include alternate exit routes.
The program director will meet with the house manager responsible for overseeing the monthly drills on 7/5/2016 to explain the proper procedure with using alternate exits during the drills. By the 8/1/2016, the program director will review the completed fire drill log to ensure that the use of alternative exits are being utilized. After reviewing the fire drill log in August, the program director will continue to monitor this process by reviewing the fire drill logs on the monthly basis. |