INITIAL COMMENTS
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This report is a result of an initial on-site physical plant inspection for a facility relocation. The inspection was conducted on October 29, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the physical plant inspection, Stairways Behavioral Health was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
Since this was a relocation inspection conducted, not all regulations were reviewed. During future inspections, all regulations will be reviewed for compliance.
The following deficiencies were identified:
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Plan of Correction
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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on the physical plant inspection, the facility failed to maintain furnishings in the living room or lounge.
The findings include:
A physical plant inspection was conducted on October 29, 2013. The facility failed to maintain furnishings in the living room or lounge.
An interview with the facility director took place on October 29, 2013. The facility director confirmed that the living room furniture was not present. The facility director also confirmed that there are plans to move the furniture from the current facility to the new location.
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Plan of Correction
Furnishings have been purchased and moved into the living room of the facility as of 11/1/13 for Clients and visitors use. |
705.6 (1) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(1) Provide bathrooms to accommodate staff, residents and other users of the facility.
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Observations
Based on a physical plant inspection, the facility failed to have hot water under pressure.
The findings include:
A physical plant inspection was conducted on October 29, 2013. At the time of the inspection, there was no hot water in the facility.
An interview with the facility director took place on October 29, 2013 at which time it was confirmed that there was no hot water as the hot water tank had been turned off.
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Plan of Correction
Hot water was restored to the facility as of 10/29/13. It was found that during a cleaning of the boiler room a wire was disconnected. It has been reconnected and hot water runs though out the building at 116 degrees. |
705.7 (b) (1) LICENSURE Food service.
705.7. Food Service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(1) Have a food preparation area with a refrigerator, a sink, a stove, an oven and cabinet space for storage.
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Observations
Based on the physical plant inspection, the facility failed to clean all eating, drinking and cooking utensils and failed to store the utensils in a clean enclosed area.
The findings include:
A physical plant inspection was conducted on October 29, 2013. The facility's new eating utensils were still in the packaging and were not cleaned and stored in an enclosed area at the time of the inspection.
An interview with the facility director took place on October 29, 2013 and the aforementioned information was confirmed.
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Plan of Correction
On 10/31/2013 all eating, drinking and cooking utensils were cleaned by running them through the dishwasher and placed in the proper drawers or cabinets in the kitchen area. |
705.10 (b) (1) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(1) Maintain a minimum of one operable, automatic smoke detector on each floor, including the basement and attic.
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Observations
Based on a physical plant inspection, the facility failed to maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire.
The findings include:
A physical plant inspection was conducted on October 29, 2013. At the time of the inspection, the facility failed to equip a bedroom so that each person with a hearing impairment would be alerted in the event of a fire.
An interview with the facility director took place on October 29, 2013 and the aforementioned information was confirmed.
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Plan of Correction
The facility contractor has ordered the hearing impaired strobe light. All wiring is in place. The light will be installed and fully functional by 11/8/13. |