INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on September 28, 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, Alternative Counseling Associates, 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 28, 2020 which revealed that the rear fire escape was in disrepair, with broken and rusted metal, which created a safety hazard.
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Plan of Correction
The piece that created the safety hazard is scheduled for welding repair. Rust will be removed and rust resistant paint applied. Maintenance technician will complete the repair.
Monthly physical plant survey will be conducted by the Maintenance Technician and/or Executive Director to be aware of facility issues to be addressed. |
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 28, 2020 The following deficiencies were observed:
damage in basement ceiling near east exit from 440 High St.
the cupola on the second floor of 438 High St there is evidence of water intrusion that has been patched.
High St. third floor apartment ceiling has water damage which has created a hole in the plaster.
eaves in the rear of building-This is a repeat citation
shingles are in poor condition with od the slate shingles crumbling or missing.
structures are in poor condition
sharp piece of metal on the outside basement stairwell from 438 High St.
bricks on the rear of 440 High St are cracked along the mortar line where the fire escape is attached for several feet.
plastic drainpipe adjacent to 440 High St. was broken and had jagged edges.
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Plan of Correction
Basement ceiling damage has been repaired by the maintenance technician.
The third floor apartment is the next unit to be vacated to undergo overall improvements. The ceiling repair is included in this. Maintenance technician is responsible; overseen by Executive Director.
The sharp piece of metal outside 438 basement was immediately removed by the maintenance technician.
The plastic drainpipe section broken will be replaced by the maintenance technician; overseen by the Executive Director. Completed 10/24/20
Monthly physical plant survey will be conducted by the Maintenance Technician and/or Executive Director to be aware of facility issues to be addressed.
Cupola, roofing, and brick work: professional estimates are being secured and will be scheduled according to professional priority recommendation and for fiscal purposes. Executive Director will secure and present to board for approval. Securing bids is presently occurring, approval and scheduling will then occur as recommended.
Under guidance of the Department, a building engineering company will conduct a building inspection on December 1,2020 and will provide written report to be submitted to the Department within 30 days.
Based on outcome of the written report, a plan will be developed and provided that addresses identified building concerns.
Mold and air quality testing is to be conducted the first week of December and results will be provided by December 30, 2020 to the Department. Roofing and masonry contractors have been secured to complete identified work on the rear of the building. Confirmation of their work completed will also be provided to the Department.
The building engineering survey was conducted on 12/1/2020, and the written assessment will be complete in about 2 weeks, but definitely prior to the end of the month.
The mold testing is Thursday 12/3/2020 with report to follow within 2 weeks.
Both reports will be submitted to the Department by no later than 12/30/20.
Facility Director has signed the contract for work with the roofer and the schedule for ACA is the last week of December. This work is inclusive of the wood replacement identified, rear slate roof, the 3rd floor rear flat roof and top flat roof.
Facility Director has also engaged a mason and is waiting on a start work date but will be prior to 12/30/2020.
The Facility Director will provide updates to the Department regarding work completion, anticipated departure from the above schedule and upon completion of all work identified in the deficiency report.
Anticipated date for completion of all work is 1/15/21.
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705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
The facility failed to maintain furniture in good repair.
office chair in basement office in 440 High St. is in poor condition.
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Plan of Correction
An office chair ordered.
Staff were reminded in a 10/8/20 agency staff meetings to submit needs for repair or replacement of furniture on the form.
Two chairs are scheduled to be ordered by the Administrative Coordinator in the next supply order on 10/20/20. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The facility failed to maintain privacy in counseling areas.
window in basement office in 440 High St. was not covered allowing unobstructed visual access to the counseling area from the alley between 440 and the neighboring building.
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Plan of Correction
Window covering was removed for washing as the staff member in the office was out for Jewish holidays and thus this would not be an issue. It was planned that no one would need the office. The covering was re-hung. Temporary window coverings will be utilized when removal for laundering takes place. Maintenance technician hang temporary covering during these times, overseen by Executive Director.
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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.
fire escape from the second-floor rear bedroom of the 438 High St. side had several pieces of wood obstructing the egress path.
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Plan of Correction
Resident monitors, when conducting rounds, will ensure residents have not moved items into the red taped-off area in front of each fire escape, visually inspect outside the egress window and visually inspect the fire escape from the ground in the rear of the building to ensure no impediments.
Any impediment was removed 9/30/20.
Resident Monitor Supervisor will instruct Monitors to record in the log that exits are clear during a rounds on second and third shifts. Resident Monitor Supervisor will monitor the documentation ongoingly beginning 10/26/20.
Maintenance technician and/or Executive Director will also conduct monthly physical plant assessment to include the fire escape.
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705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
The facility failed to light interior stairs at all times.
second-floor landings in the stairwell in both the 438 and 440 High St. buildings were not illuminated.
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Plan of Correction
Lighting will be installed in the 2nd floor stairwell for improved illumination. Maintenance Technician or outside contractor will complete as installation determined; overseen by Executive Director.
Completed by the Maintenance Technician 11/13. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
The facility failed to ensure all fire extinguishers are inspected annually.
basement fire extinguisher in the 438 High St. building did not have an annual inspection tag.
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Plan of Correction
The fire extinguisher inspection took place on 7/23/20 and the inspection report includes the basement extinguishers. The new tag is missing and the fire solution company has been contacted and is replacing.
A monthly physical plant review will take place by the Maintenance Technician and/or Executive Director and will include ensuring inspection tags remain present on extinguishers. |
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 June 12, 2020 a verbal confrontation between two employees escalated and the police were called. The police arrived on-site after the confrontation had subsided and no action was taken; this was confirmed with the facility staff however, no unusual incident report was submitted to the Department.
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Plan of Correction
Incident reports will be submitted all occurrences of police, fire or EMT personnel on site. The online reporting system will be utilized. Executive Director is responsible. |