INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 20-21, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Esper Treatment Center 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:
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Plan of Correction
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate two of two client bathrooms by exhaust fan or window.
The findings include:
A physical plant inspection was conducted on May 21, 2014. The facility has a men's bathroom and a women's bathroom that the clients utilize. The bathrooms do not have a window. The facility failed to ventilate the two client bathrooms as the exhaust fans in both of the bathrooms were inoperable at the time of inspection.
The Project/Facility Director was interviewed on May 21, 2014 and confirmed the findings.
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Plan of Correction
The fans in both bathrooms will be serviced and replaced if necessary. Will ensure that both fans are on a separate breaker to ensure that they are working. The Project Director and Safety Officer will ensure that they are functioning properly. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the 2013 annual report, the governing body failed to make available to the public an annual report that included a financial statement of income and expenses.
The findings include:
The annual report for the year ending December 31, 2013 was reviewed on May 21, 2014. The governing body failed to include a financial statement of income and expenses in the 2013 annual report.
The Project/Facility Director was interviewed on May 21, 2014 and confirmed the findings.
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Plan of Correction
The Annual Report will include Revenues and Expenditures in the accomplishments portion of the report. The Project Director will ensure that it is reflected in the 2014 report and will amend the 2013 report |