INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 5, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Retreat at White Birch 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:
|
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 on November 5, 2025, 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. Four window screens located in the dayroom on first floor at the back of the building were torn and damaged. There was also a broken wall mirror attached above the sink in resident bedroom #205.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
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. Four window screens located in the first-floor dayroom at the back of the building were torn and damaged. There was also a broken wall mirror attached above the sink in resident bedroom #205.
? Corrective Action Taken to Address the Deficiency
- The four damaged window screens were removed and taken to a licensed window repair shop for replacement. New screens will be installed upon return.
- The broken medicine cabinet mirror in resident room #205 will be removed and replaced with a new unit.
Measures to Ensure the Deficiency Does Not Recur
- The Clinical Supervisor and Community Managers will conduct weekly interior rounds to ensure all areas are clean, safe, sanitary, and in good repair. Any concerns will be immediately reported to the Project Director.
- The Project Director will conduct weekly exterior inspections, including inspection of window screens and building structure, and will address repairs promptly.
- All maintenance issues will be logged and tracked until resolved.
Person(s) Responsible
Clinical Supervisor
Community Managers
Project Director
|
705.5 (h) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(h) Each bedroom shall be ventilated by operable windows or have mechanical ventilation.
|
Observations
Based on a physical plant inspection on November 5, 2025, the facility failed to ventilate each bedroom by operable windows or have mechanical ventilation.It was observed the only window handle in resident bedroom #207 was missing the handle making the window inoperable.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to ventilate each bedroom by operable windows or provide mechanical ventilation. During the licensing inspection, it was observed that the only window in resident bedroom #207 was missing its handle, making the window inoperable. These findings were reviewed with facility staff during the licensing process.
Corrective Action Taken
A replacement window handle for resident bedroom #207 was ordered immediately following the inspection.
Upon receipt, maintenance staff installed the new handle, restoring the window to full operability.
The window function was tested to ensure proper ventilation and ease of use.
Plan to Prevent Recurrence
The Clinical Supervisor and Community Managers will conduct weekly interior room inspections, ensuring all bedroom windows are operable and free from damage.
Any missing, loose, or malfunctioning window hardware will be reported immediately to the Project Manager for repair or replacement.
The Project Manager will maintain a small inventory of essential window hardware (handles, cranks, locks) to allow timely repairs.
The weekly inspection checklist will include a required window operability check to ensure consistent monitoring. |
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.
|
Observations
Based on physical plant inspection on November 5, 2025, the facility failed to provide slip-resistant surfaces in all bathtubs and showers.During the licensing process it was observed the resident ' s bathroom showers and tubs did not have slip resistant surfaces in the second-floor communal bathroom.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to provide slip-resistant surfaces in all bathtubs and showers. During the licensing inspection on November 5, 2025, it was observed that the resident bathrooms in the second-floor communal area did not have slip-resistant surfaces in the showers and tubs. These findings were reviewed with facility staff during the licensing process.
Slip-resistant mats were purchased and installed in all second-floor communal bathroom showers and tubs.
Measures to Ensure the Deficiency Does Not Recur
- The Clinical Supervisor and Community Managers will complete weekly interior facility rounds, including inspection of all bathing areas to ensure slip-resistant surfaces are in place and in good condition.
- Any missing, damaged, or worn slip-resistant mats will be reported immediately to the Project Director for replacement.
- The Project Director will maintain a supply of approved slip-resistant mats onsite to ensure timely replacement as needed.
? Person(s) Responsible
Clinical Supervisor
Community Managers
Project Manager
|