INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on February 13-14, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, French Creek Recovery Center 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:
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Plan of Correction
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection conducted on 2/13/2024, the facility failed to have a wall mirror in the restroom, located on the first floor, detox wing.
This was discussed with facility staff during the physical plant inspection.
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Plan of Correction
On 2/22/24, DPO installed a wall mirror in the designated area. The Director of Plant Operations completed an audit on 2/21/24 to ensure all restrooms had a wall mirror. DPO revised monthly EOC audit to ensure all bathrooms include a wall mirror. The goal of the audit will be to ensure that all restrooms have a wall mirror with a goal of 100% compliance each month. Oversight of compliance will be monitored quarterly by the committee of the whole. In the event that non-compliance is identified, the plan operations manager will be re-educated and/or receive appropriate disciplinary action. No additional negative findings were noted. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection conducted on 2/13/2024, the facility failed to have slip-resistant mats in two bathrooms, located on the first floor, detox wing.
This was discussed with facility staff during the physical plant inspection.
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Plan of Correction
On 2/21/24, DPO replaced the non-slip bathmats in the designated area. The Director of Plant Operations completed an audit on 2/21/24 to ensure all restrooms had slip-resistant mats. DPO revised monthly EOC audit to ensure all bathrooms include slip-resistant mats. The goal of the audit will be to ensure that all restrooms have a slip-resistant mat with a goal of 100% compliance each month. Oversight of compliance will be monitored quarterly by the committee of the whole. In the event that non-compliance is identified, the plan operations manager will be re-educated and/or receive appropriate disciplinary action. No additional negative findings were noted. |
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 2/13/2024, the facility failed to maintain a bathroom that is functional as the bathroom located on the 2nd floor, women's wing, rooms 228/227 had a cabinet located under the sink that was broken and missing drawers.
This was discussed with facility staff during the physical plant inspection.
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Plan of Correction
On 2/21/24, DPO removed the cabinet under the sink that had missing drawers and broken. The Director of Plant Operations completed an audit on 2/21/24 to ensure all bathrooms were functional. DPO revised monthly EOC audit to ensure all bathrooms are functional. The goal of the audit will be to ensure that all restrooms are functional with a goal of 100% compliance each month. Oversight of compliance will be monitored quarterly by the committee of the whole. In the event that non-compliance is identified, the plan operations manager will be re-educated and/or receive appropriate disciplinary action. No additional negative findings were noted. |