INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and capacity increase conducted on May 26, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Endless Mountains Extended Care, LLC 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 (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
During a physical site inspection on May 26, 2021, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The bathroom in room eleven had water damage to the ceiling. The ceiling was peeling, and pieces were hanging down.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On May 28, 2021 in order to be in compliance with 705.6, the property manager made all necessary repairs to the ceiling in bathroom 11. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
During a review of fire drill records on May 26, 2021, the facility failed to conduct a fire drill during sleeping hours at least every six months.
From August 2020 through May 2021, the only documented sleeping fire drill was on November 4, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On May 26, 2021; the facility coordinator was instructed to make sure he always documents AM/PM in the time slot on each and every fire drill report in order to be compliant with 705.10. The Facility Coordinator was counseled by the Facility Director on 5/26/21 on the importance of proper fire drill documentation, and all expectations were communicated to ensure compliance in the future. Fire drills and subsequent documentation is current as of today; June 10, 2021. |