INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 21-22, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cornell Abraxas I 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 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on a physical plant inspection, the facility failed to provide securely attached rails to the bunk beds.
The physical plant inspection was conducted on March 22, 2022. The majority of the bunk beds in the male dorms were observed to be open and not having a securely attached rail.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 23, 2022, the Compliance Director advised the Treatment Supervisor II of the Male D/A Program (Seneca dorm) of this regulation and the citation. She instructed the TSII to have the staff and residents turn all of the bunk beds around so the railing for the long side of the mattress is on the outside, rather than against the wall. On March 25, 2022, the Program Manager verified the bunk beds being used by clients were all turned correctly so the secure railing was on all open sides of the mattress. The few beds that did not have a secure rail were not being used by clients and were repaired by the Maintenance Department on April 11, 2022. The Treatment Supervisor II will review this requirement with the Seneca dorm staff during their April team meeting and document their discussion in the meeting notes. Treatment Supervisors will assess the condition of bunk beds at least weekly during their physical plant assessment of the dorm. The Program Manager will monitor this plan of correction by walking through the male dorm at least weekly for 60 days to verify the bunk beds have a secure railing on all three sides of the mattresses. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to document unannounced fire drills at least once a month.
The fire drill records were reviewed for all of the drug and alcohol treatment dorms. There was no fire drill conducted in the Seneca dorm for the month of October 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Safety/Infection Control Committee identified this as a problem in November 2021. At that time, the committee established the expectation with supervisors that monthly fire drills must be completed no later than the 20th day of the month. The facility's Safety Officer collects the documentation of each fire drill and verifies each dorm's drill was complete, correct, and performed on the assigned shift. If a drill is not completed by the 20th of the month, the Safety Officer notifies the Treatment Supervisors and the entire administrative team. Program Managers follow up immediately to make sure the drills are completed. During their monthly meeting (held on the next to last Thursday of the month), the Safety/Infection Control Committee reviews and monitors fire drill documentation to verify all drills were completed. |