INITIAL COMMENTS
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This report is a result of an initial on-site licensure inspection conducted on November 14, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Project Transition (Greenbriar) - Philadelphia was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
Since this was the initial inspection conducted, not all regulations were reviewed. During future surveys all regulations will be reviewed for compliance.
The following deficiencies were identified.
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Plan of Correction
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate the bathrooms by an exhaust fan or window.
Findings:
A physical plant inspection was conducted with the facility quality assurance staff on November 14, 2011 between the hours of 10:00 and 10:15 The exhaust fan in the bathroom was not operative at the time of the inspection and bathroom does not have a window.
Quality assurance staff confirmed the exhaust fan in the bathroom was not operative and the bathroom does not have the benefit of a window.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 on a physical plant inspection, the facility failed to provide an unobstructed exit from the rear of the building.
Findings:
A physical plant inspection was conducted on November 14, 2011 between the hours of 10:15 and 10:30. A file cabinet and cardboard boxes partially blocked the exit, which caused the emergency exit to be obstructed.
Quality assurance staff , who guided the inspection on November 14, 2011 between the hours of 10:15 and 10:30, were present when the file cabinet and cardboard boxes obstructed the exit.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |