INITIAL COMMENTS
|
This report is a result of an on-site licensure inspection conducted on September 13 - 14, 2010 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site inspection, Horizon House, Inc. 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 and a plan of correction is due on October 19, 2010.
|
Plan of Correction
|
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.
|
Observations
Based on a physical plant inspection and an interview with the Facility Director, the facility failed to 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 findings include:
A physical plant inspection was conducted on September 14, 2010 at approximately 1:30 PM.
It was observed that the small restroom on the second floor had peeling and chipping paint, the walls were marred, the floor tile was worn and coming up and the door and door jamb needed sanded and repainted.
Torn treads were observed on the hallway stairs.
The carpeting on the third floor were soiled and needed to be cleaned.
The carpeting in room # 5 on the second floor was soiled and needed to be cleaned. This room also had marred walls and peeling paint on the trim.
There was a multiple bulb wall mounted light fixture located in the third floor bathroom that was in disrepair. Several sockets were loose at the base of the fixture.
There was a light fixture located in bedroom # 1 that was missing a cover.
The basement had falling ceiling tiles and plaster, and exposed and unsecured wires.
The Facility Director and a representative from the realty division confirmed that repairs needed to made in order to promote the safety and well-being of residents, employees and visitors.
|
Plan of Correction
For all physical plant issues, effective immediately the House Manager will conduct daily checks and document any issue that needs addressing. These issues will be address in the daily morning team meetings. A work order will be completed and submitted to the Horizon House Real Estate Dept following these meetings for all needed repairs.
The Real Estate Department at Horizon House will schedule the 2nd floor bathroom renovations which will include preparing the walls and door jam to be painted and replace the floor tiles. The work will be completed by 12/30/10.
The treads on the hallway stairs were replaced 9/29/10.
Effective immediately, the House Manager will monitor and maintain the cleanliness of the carpet. The carpets on the third floor and in room #5 have been cleaned on 10/6/10.
The house manager submitted the work order on 9/30/10 to the Real Estate department to address the marred walls and peeling paint trim in room #5, the light fixture located in the third floor bathroom, the light fixture located bedroom #1, the basement ceiling tiles and plaster, and exposed and insecure wires in the basement.
The work will be completed by October 29, 2010
|
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
|
Observations
Based on a physical plant inspection, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A physical plant inspection was conducted at approximately 1:30 PM on September 14, 2010.
Trash was observed in an uncovered dumpster, and there were three other trash cans that were uncovered.
|
Plan of Correction
The house manager will supervise staff to ensure that the garbage lid is kept closed. Signs were posted on the garbage enclosure on 9/16/10 to remind staff to keep the lid on the garbage at all times. The house manager will review the garbage disposal procedures with staff in the next monthly staff meeting on 10/13/10. |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
|
Observations
Based on a physical plant inspection and an interview with the Facility Director and a representative from the realty division, the facility failed to maintain the building to be free of rodent and insect infestation.
The findings include:
A physical plant inspection was conducted on September 14, 2010 at approximately 1:30 PM.
At the time of inspection, the facility had a bedbug infestation in Room # 8.
The licensing supervisor identified blood stains on a sheet in a room that was currently occupied adjacent to room # 8..
The Facility Director confirmed before the physical inspection that Room # 8 was infested with bed bugs and that the room was vacant.
In addition, a representative from the realty division stated that she two bed bugs were seen in room # 8 earlier that morning. The representative stated, that they tried to get the exterminator over that day, but that the exterminator could not come until the following day.
|
Plan of Correction
The house manager will oversee the management and treatment of the bed bugs. There are protocols in place to address the bed bug issue, and a policy and procedure will be completed by 12/30/10 and implemented by 1/31/11. The exterminator arrived on the site on 9/15/10 and exterminated the entire facility. They will return to complete periodic scheduled visits to ensure the bed bugs are eradicated. |
705.9 (4) (i) 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:
(i) The evacuation and transfer of residents and staff to a safe location.
|
Observations
Based upon a review of the facility's policies and procedures manual and staff interviews, the facility failed to provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of residents and staff to a safe location.
The findings include:
On September 14, 2010 the Facility Director and a representative from the facility's realty division were asked if the facility had experienced any problems with bed bugs. Both had indicated that the facility had been battling bedbugs since July 2009 and had recently signed a contract with a new exterminator due to the dissatisfaction of the treatment methods used by the previous company. The representative from the facility's realty unit indicated that bedroom # 8 had an infestation and that two bed bugs were seen in that room earlier that morning, the representative went on to say that the exterminator was contacted but that they would not be able to come until that following day.
The Facility Director was asked if the facility had a policy and procedure in place to deal with the bed bug situation. The director indicated that they did not have a policy and procedure in place but that they did have a draft protocol that they were presently following. A copy of the draft protocol was reviewed; however, it had not yet been fully developed nor had it received board approval. In addition the protocol failed to identify the evacuation and transfer of residents and staff to a safe location should the bed bug problem rise to a level whereby the building would need to be evacuated.
|
Plan of Correction
Pest Infestation policy and procedure will be completed by the Real Estate Department by December 30, 2010. Review by the Board is scheduled for January 11, 2011 and implementation is slated for January 31, 2011.
Horizon House's Emergency Preparedness Policy and Procedure 4.3.1 addresses the evacuation and transfer procedure of residents and staff to a safe location in the event that an evacuation is needed. The site also has an Emergency Plan that outlines the step-by-step actions for evacuation or shelter-in-place.
|
705.10 (b) (2) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(2) On floors with resident bedrooms, maintain a smoke detector which shall be located within 15 feet of each bedroom door. On floors with no resident bedrooms, the smoke detection device shall be located in a common area or hallway. All detection devices shall be interconnected.
|
Observations
Based on a physical plant tour, an interview with the facilities maintenance team, the representative from the facility's realty division, and the alarm company that conducted an on-site test of the alarm system, the facility failed to maintain smoke detectors as part of an interconnected system on floors with resident bedrooms.
The findings include:
On September 15, 2010 at approximately 1:30 PM a physical plant inspection was conducted.
It was observed that the smoke detectors on the second and third floors, and the basement were inoperable.
Artifical smoke was used to test the smoke detectors on floors two and three, as well as the basement, and the smoke detectors failed to activate.
An interview with the buildings maintenance team and the alarm company representative was conducted at which time they confirmed that the smoke detectors were inoperable and unable to be repaired within 48 hours as parts had to be ordered.
The facility did place battery operated smoke detectors on those floors and was in the process of implementing an hourly fire watch to provide some level of safety until the smoke detection system was repaired.
|
Plan of Correction
The smoke detectors on the second and third floors, and the basement were repaired on 9/27/10. The smoke detectors will continue to be monitored and checked monthly and any issues will be documented, and a work order will be submitted to the HH Real Estate Dept. |