INITIAL COMMENTS
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This report is a result of an initial on-site physical plant inspection following a facility relocation. The inspection was conducted on June 23, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the physical plant inspection, Kensington Hospital Outpatient Treatment 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: Since this inspection was just for a physical plant relocation, not all regulations were reviewed. During future inspections, all regulations will be reviewed for compliance.
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Plan of Correction
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential 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 clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based upon observation during the physical plant inspection, the facility failed keep the grounds of the facility in good repair.The Bilco door was damaged and there was a gap where it met the building that would allow for water to get into the basement.
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Plan of Correction
The Bilco doors are being replaced with new Bilco doors. The doors have been installed and the gap has been repair. The doors and gap are now water tight, and have been inspected by the directed of environmental services. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based upon observation during the physical plant inspection, the facility failed to ensure that all exits were unobstructed.During the physical plant inspection it was observed that the facility had a padlock on the gates of the parking lot. Two of the exit discharges, discharged into that parking lot.The second exit from the basement (bilco doors) had a padlock on the exterior of the doors preventing egress from inside of the building.
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Plan of Correction
the new bilco doors have been install there is no exterior lock on the doors.There will only be a panic bar install on the inside of the bilco doors to exit from the basement only. Also a Mag lock was install and wired to the fire alarm systerm and the gate will open when a alarm goes off, there is also a touch pad for opening the gate manual all work has been completed and inspected by Director of Environmental Services. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
Based upon observation during the physical plant inspection, the facility failed to ensure that each ramp, interior stairway and outside steps exceeding two steps had a well-secured handrail.The steps serving the second exit from the basement (bilco doors) lacked a handrail.
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Plan of Correction
A new handrail has been install at the second exit in the basement to the street, also there is only one step at the front entrance,and there is a handicapped entrance from the parking lot that is at ground level. also there are signs in the parking lot and at the front entrance that indicates a handicapped entrance. this has been inspected and will also be monitored by Director of Environmental Services. |
711.94(b) LICENSURE Display Hours of Operation
711.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based upon observation during the physical plant inspection, the facility failed to conspicuously display the hours of operation to the public.At the time of the inspection, the hours of operation were not posted to the general public.
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Plan of Correction
A sign have been install with the hours of operation and placed in the Window By the maintenance staff,and was inspected and will be monitored by Director of Environmental Services. |
711.94(c) LICENSURE Display Emerg. Telephone Number
711.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based upon observation during the physical plant inspection, the facility failed to conspicuously display a telephone number to the general public for emergency purposes. At the time of the inspection, a telephone number for emergency purposes was not posted.
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Plan of Correction
A the Emergency telephone number was install on the window by the front door by the maintenance staff and will be inspected and monitored by the Director of Environmental Services. |