INITIAL COMMENTS
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This report is a result of an onsite physical plant inspection conducted on September 12, 2017 by staff from the Division of Program Licensure for the licensure renewal. Based on the findings of the inspection, North Philadelphia Health System Goldman Clinic was found to be out of compliance 28 Pa. Code chapter 705.21 Physical Plant Standards. Because this was just a physical plant inspection not all regulations were looked at during this inspection. The facility has the following deficiencies:
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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
Based on observation on September 12, 2017, the facility failed maintain all structures on the grounds of the facility so as to be free from any danger to health and safety.
The findings include the following:
The facility had water damage to the interior of the building at the common exterior walls at the following location:
Exterior wall of the corridor at the very end,beyond the passage to the stairtower.
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Plan of Correction
The Director of Facilities Management will repair the damage to the interior wall on or before 10//20/17.
To monitor and ensure that this deficiency does not recur the floor staff will conduct weekly environmental rounds and report needed repairs to the maintenance department |
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
Based on observation on September 12, 2017, the facility failed to maintain counseling areas with furnshings that were in good repair.
The findings include the following:
The group room on the seventh floor had the following issues:
Chairs that had rips in the fabric
Broken slats in the window blinds
Marred walls and doors
Water stains in the lighting fixture
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Plan of Correction
The Program Director will order replacement blinds and furniture on or before October 20, 2017
The Facilities management director will have the walls and doors painted on or before October 27, 2017.
The Facilities director will have the lighting fixture cleaned on or before 10/20/17
To monitor and ensure that this deficiency does not recur the floor staff will conduct weekly environmental rounds and report needed repairs to the maintenance department |
705.5 (a) (3) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(3) A storage area for clothing.
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Observations
Based on observation on September 12, 2017, the facility failed maintain the storage area for clothing.
The findings include the following:
The facility had a dresser with a missing drawer in room 905.
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Plan of Correction
The Program Director will order a replacement dresser on or before 10/20/17.
To monitor and ensure that this deficiency does not recur the floor staff will conduct weekly environmental rounds and report needed repairs to the maintenance department
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705.5 (h) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(h) Each bedroom shall be ventilated by operable windows or have mechanical ventilation.
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Observations
Based upon observation on September 12, 2017, the facility failed to ensure that the bathrooms were ventilated by operable exhaust fans or operable widows.
The findings include the following:
The following bathroom exhausts were not working at the time of the inspection and there were no operable windows in the bathrooms:
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Plan of Correction
The Director of Facilities management will have the motors repaired in all bathroom exhaust on or before October 20, 2017.
To monitor and ensure that this deficiency does not recur the floor staff will conduct weekly environmental rounds and report needed repairs to the maintenance department |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based upon observation on September 12, 2017, the facility failed to ensure that showers were provided with slip resistant surfaces.
The findings include the following:
The following bathrooms lacked slip resistant surfaces for showers:
Both shower rooms located on the seventh floor
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Plan of Correction
The Director of Facilities management will have slip resistant decals placed on the floors of all showers on or before October 20, 2017.
To monitor and ensure that this deficiency does not recur the floor staff will conduct weekly environmental rounds and report needed repairs to the maintenance department |
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
Based upon observation on September 12, 2017, the facility failed to ensure that the bathrooms were maintained in a functional, clean and sanitary manner at all times.
The findings include the following:
The shower in room 905 had a section where edges of ceramic tile were exposed due to a missing tile soap dish.
The interior wall of the bathroom common to the exterior wall had water damage.
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Plan of Correction
The Director of Facilities management will repair the shower tile and the interior all of the bathroom on or before 10/20/2017.
To monitor and ensure that this deficiency does not recur the floor staff will conduct weekly environmental rounds and report needed repairs to the maintenance department
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