INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on September 28, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Beyond Addiction Recovery and Treatment was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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.
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Observations
Based on a complaint investigation conducted on September 28, 2023, the facility failed to keep the grounds of the facility in good repair at all times. The facility also failed to keep the building grounds free of hazards. The group room had paint chipping off the wall near the base molding.The parking lot had several potholes. The driveway leading into the parking lot also had several deep potholes.
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Plan of Correction
The Executive Director met with the contractor/excavation team on 10/25/2023 to discuss the driveway. The one side of the driveway will be permanently closed as of 11/21/23. The driveway gets too much water going through that area to repair annually. We will change the driveway to have one entrance and the signage to reflect that.
The rest of the driveway will have potholes filled and sealed by 12/31/2023.
The paint in the group room will be fixed by 11/21/23.
The driveway and physical plant standards of the facility will be monitored monthly by the Director of Operations and maintenance will be contacted if issues present themselves.
A maintenance contract was entered into on 10/27/2023 with a local company to attend to any maintenance issues. This will also be monitored and controlled by the Director of Operations. |