INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 16-19, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, BGI of Brandywine, Inc., 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 (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
Based on a physical plant inspection, conducted on July 17, 2018, the facility failed to keep the facility free from hazards.
The laundry area located next to The Motel section, had trash and an accumulation of lint behind the dryers that created a safety hazard.
Additionally, the sink next to the washing machines contained trash and had clumps of wet lint, and dirt in the bottom of the basin.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The laundry area was cleaned on 7/18/18. The Housekeeping Supervisor will implement a checklist by 9/10/18 for checking the cleanliness of this room daily. The Plant Operations Manager will review the checklist for compliance during his weekly rounds. |
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 July 17, 2018, the facility failed to maintain the bathrooms in a clean, sanitary and functional manner.
The bathroom in room number 21 had exposed electrical wires in the baseboard heating element.
Additionally, the cover for the wires was broken which created a sharp edge and presented another safety hazard.
The bathroom in the partial hospitalization programming area had a broken faucet handle.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The heater in room 21's bathroom was fixed on 7/20/18.
The faucet in the partial bathroom was fixed on 7/18/18.
The Plant Operations Manager implemented weekly maintenance rounds for the facility on 8/1/18. The documentation for these rounds will be reviewed during the monthly Safety Committee meetings to ensure compliance. |
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
Based on a physical plant inspection, conducted on July 17, 2018, the facility failed to ensure that exits from the facility were unobstructed.
The rear exit from the Garden Room was unable to be opened due to a problem with a screw in the threshold; this issue was corrected by the facility during the inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The fire exit door in the Garden Room was fixed on 7/18/18. The Plant Operations Manager implemented a weekly check of all items related to Fire Safety (signs, doors, etc) for all buildings on 8/1/18. The documentation of these checks will be reviewed during the monthly Safety Committee meetings to ensure compliance. |