INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 1 - 2, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, The Highland 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.
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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 ensure that the residential structure and grounds were free from danger to the health and safety of clients, staff and visitors based on a physical plant inspection conducted with the project/facility director on July 1, 2019 at approximately 11 AM.
The following unsafe conditions were observed:
The fire escape at the rear of the building was found to have rotted wood and the sections of wood that were attached to the building were splitting around the fasteners. Additionally, the stair treads had nails that were uneven and did not provide a firm platform on which to step.
The sidewalk under the fire escape was broken and cracked which created a trip hazard.
There were loose wires hanging from a light fixture on the front porch near the front door.
There were loose and broken boards on the main stairs to the front entry and on the front porch.
There was evidence of water intrusion in the basement and a black substance was covering the wall nearest to the exit.
The findings were reviewed with facility staff during the licensing process.
These deficiencies were initially identified during an investigation conducted on March 10 - 11, 2019. The plan of correction was not yet due as of the date of the licensing inspection on July 1 - 2, 2019.
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Plan of Correction
The Executive Director placed caution tape at both entrances of the fire escape so that it could not be used by residents or staff. The Executive Director asked the New Castle Fire Department look at the fire escape on 4/23/19 as well as code enforcement on 4/26/19. The report from the fire department for the entire facility was sent in a separate email to DDAP. Code enforcement reported that if any repairs or replacement would need done architectural drawings would be necessary and a building permit would be needed to make said repairs. The Code Enforcement officer sent me a letter with this information which was forwarded in a separate email to DDAP.
Executive Director arranged for an engineer to provide an inspection and estimate of the work to be completed. The Executive Director will work with an architect to have the drawings completed, and the engineer also serve as the project manager and place the project out for bid a 2nd time. The Executive Director will work with the chosen project manager to report the bids to the Board of Directors so that work can begin on the project. The Executive Director will work with the chosen contractor and project director to determine the start date and estimated time to complete the project. The estimated completion of the project is October 22, 2019. The repair of the sidewalk will be included with the fire escape project.
A sample of the black substance was obtained by the Executive Director and was sent to an authorized lab for evaluation on 4/29/19.Evaluation of the black substance was received and indicated to be non-hazardous. This report was sent in a previous email to DDAP.
The Executive Director has obtained an electrician that has inspected the loose wires on the front porch. The light has been replaced and the wires are not live, the electrician is removing the wires with another electrical project.
A contractor has been obtained to begin work on the main stairs to the front entry on the front porch, work is estimated to begin by 8/3/2019 with an approximate completion date of 10/22/2019.
The safety committee will meet quarterly, during this time they will do a site inspection of the inside and outside of the facility and address any maintenance or safety issues. Also, a maintenance form was created so as staff observe any maintenance or safety issue they can turn the form into their direct supervisor and appropriate repair people can be contacted. A maintenance schedule was also created by the Operations Manager and introduced to the staff before 7/15/2019.
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705.9 (4) (iii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(iii) The evacuation and transfer of residents impaired by alcohol or other drugs.
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Observations
The facility failed to provide documentation of a written procedure for staff and residents to follow in case of an emergency that included the evacuation and transfer of residents impaired by alcohol or other drugs based on a review on the facility's policy and procedure manual on July 1, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director will add to the policy in place and include a procedure for evacuation and transfer of residents impaired by alcohol or other drugs by 7/24/19. |
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 all interior exits and stairs based on a physical plant inspection conducted with the project/facility director on July 1, 2019 at approximately 11 AM.
The stairwell from the basement to the outside through the Bilco doors was not illuminated. The light fixture was observed to be inoperative.
In addition, the facility failed to indicate exits by the use of signs.
The emergency exit located in bedroom # 5 on the third floor was not posted.
The findings were reviewed with facility staff during the licensing process.
The deficiency pertaining to the lighting for the interior stairs/exit was initially identified during an investigation conducted on March 10 - 11, 2019. The plan of correction was not yet due as of the date of the licensing inspection on July 1 - 2, 2019.
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Plan of Correction
The Executive Director hired an electrician who has started repairs and is replacing the light fixture outside the bilco doors, and removing necessary fixtures and wiring. Estimated completion of the project is 8/22/2019.
On July 3rd, 2019, the Executive Director posted a sign indicating that the emergency exit was located in bedroom #5 on the 3rd floor.
The safety committee will meet quarterly and do a site inspection to maintain the safety and maintenance of the facility. Necessary repairs will be scheduled by the Executive Director or the Operations Manager. A maintenance form was created that can be used by all staff to report any maintenance or safety issues to their direct supervisor. The appropriate repair person will then be scheduled by the supervisor, Executive Director or Operations Manager. A maintenance schedule was created by the Operations Manager and introduced to the staff before 7/15/19. |