INITIAL COMMENTS
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This report is a result of an on-site physical plant inspection conducted for a capacity increase request. The inspection was conducted on May 3, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Ellen O'Brien Gaiser Addiction Center 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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705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on observation and a physical plant inspection, the facility failed to provide beds or furniture in the three newly remodeled bedrooms.
The findings include:
A physical plant inspection was completed on May 3, 2011. The facility is requesting a capacity increase based on the three newly remodeled bedrooms, but the furniture was not available at the time of the physical plant inspection.
The director confirmed the furniture was ordered, but as of the date of the inspection, had not arrived.
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Plan of Correction
Two bunk beds with fire retardant mattresses in accordance with FF 4-72 amended, 16 CFR part 1632 were delivered and set up on Wednesday May 25, 2011. The Gaiser Center is asking for a licensing increase of four (4) at this time although capacity exists for a maximum of eight additional clients. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on observation and a physical plant inspection, the facility failed to provide a wall mirror in the newly remodeled bathroom.
The findings include:
A physical plant inspection was completed on May 3, 2011. The wall mirror was not available at the time of the physical plant inspection.
The director confirmed the wall mirror was not in the bathroom.
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Plan of Correction
The Gaiser Center maintenance man under the direction of the Executive Director installed a bathroom mirror above the sink on May 5, 2011. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on observation and a physical plant inspection, the facility failed to secure discharged client records within locked storage containers.
The findings include:
A physical plant inspection was completed on May 3, 2011. At the time of the physical plant inspection, there were boxes of discharged client records located in a basement closet. The closet was unlocked, and contained other items along with the unsecured boxes of client records.
The director confirmed the client records were not secured within a locked storage container.
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Plan of Correction
During the inspection on 5/3/11 a basement door was erroneously left unlocked. The Executive Director facilitated a impromptu staff meeting on 5/4/11 to review the confidentiality laws and Gaiser Center policies on client confidentiality. All client files must be secured in locked storage containers and all staff will be in compliance with said laws and policies.
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