INITIAL COMMENTS
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This report is a result of an initial on-site physical plant inspection preceding a facility relocation. The inspection was conducted on June 1, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the physical plant inspection, Catholic Charities Diocese of Harrisburg, PA, Inc. 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.
Since this was a physical plant inspection preceding a facility relocation, not all regulations were reviewed. During future inspections, all regulations will be reviewed for compliance.
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Plan of Correction
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the observation during the physical plant inspection, the facility failed to ensure privacy in order to insure that counseling sessions cannot be seen or heard outside the counseling room.
The findings include:
A physical plant inspection took place on June 1, 2012. During the physical plant inspection, Room 23-D failed to have window coverings hung. This would allow counseling sessions to be seen from the outside the facility.
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Plan of Correction
Curtains or blinds will be hung in Room 23-D, counseling office, by the maintenance department (Asst Director of Building and Properties) and verified by the Program Director. Daily room checks and monthly building inspection performed by assigned support staff will ensure that missing blinds/curtains are replaced each week. The inpsection results are reported to the PD who then assigns support staff to pick up supplies during weekly store runs. |
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 during a physical plant inspection, the facility failed to have documentation of fire retardant mattresses.
The findings include:
A physical plant inspection took place on June 1, 2012. The facility was requested to produce documentation that the mattresses were fire retardant. The facility director stated that the information for the mattresses is at the existing facility and was not available during this site inspection.
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Plan of Correction
15 mattresses from the original facility will be transported the day of the move. These mattresses have previous documentation of being fire retardant as evident by a statement from the Serta Company who manufactured the mattresses. Additional fire retardant mattresses will be purchased by the Program Director to accommodate the move and expansion request. The mattresses will be of the same brand and therefore the standing statement from the Serta Company will apply to the new mattresses. The Program Director will secure mattresses and documentation. |
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 during the physical plant inspection, the facility failed to have an operable soap dispenser and either individual paper towels or a mechanical dryer in each bathroom.
The findings include:
Fifteen bathrooms were observed during the physical plant inspection on June 1, 2012. The physical plant inspection took place between 2:00 p.m. and 3:30 p.m. Ten of fifteen bathrooms were observed to need to have an operable soap dispenser and either individual paper towels or a mechanical dryer, specifically in rooms 13-D, 14-D, 15-D, 16-D, 17-D, 24-D, 25-D, 26-D, 27-D and 28-D.
This finding was confirmed by the facility director and was not disputed.
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Plan of Correction
The Program Director purchased 15 manual soap dispensers and 15 baskets to hold paper towels. Each bathroom has a soap dispenser and basket. Paper towels were also purchased and all baskets were filled with paper towels. Soap dispensers and baskets will be refilled each day as needed when program is operable. The Program Director has verified that this Plan of Correction has been completed. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on observation the facility failed to have hot water during the physical plant inspection.
The findings include:
The physical plant inspection took place on June 1, 2012. At approximately 2:15 p.m. the hot water pressure was tested. The temperature did not register to any degree of heat.
The staff confirmed that the hot water was not operational.
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Plan of Correction
The water temperature will be adjusted to provide hot water and not exceed 120 degrees. The adjustment will be completed by the maintenance department (Asst Director of Building and Properties) and verified by the Program Director. Monthly inspections completed by assigned support staff will report to the PD any temperature discrepancies who will then contact the maintenance department to repair. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection, the facility failed to provide privacy in showers by partitions, doors or curtains.
The findings include:
A physical plant inspection was conducted on June 1, 2012. All bathtubs/showers are required to have privacy by partitions, doors or curtains. One of two bathrooms equipped with a shower failed to have a partition, door, or curtain. The facility did not provide a shower curtain or door in bathroom D-2.
This finding was confirmed by the facility director.
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Plan of Correction
A shower curtain was installed in bathroom D-2 by the maintenance department (Asst Director of Building and Properties) and verified by the Program Director. Daily and monthly building inspections completed by house managers will prevent this deficiency occurring again and be reported to the PD who will purchase another curtain within that week and comply with DOH regulations. Extra curtains will also be kept in the linen closet. DOH will be kept informed once compliance issues have been resolved. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on observation during the physical plant inspection, the facility failed to have a functional toilet in four of fifteen bathrooms.
The findings included:
Fifteen bathrooms were observed during the physical plant inspection on June 1, 2012. Bedrooms # 24-D, 25-D, 27-D and 28- D failed to have a toilet installed. There was a hole in the floor where the toilet should be mounted.
This finding was confirmed by the facility director and was not disputed.
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Plan of Correction
Four toilets will be installed and functioning by the maintenance department (Asst Director of Building and Properties) and verified by the Program Director. Daily and monthly building inspections will be completed by house managers who will report any damaged toilets to the PD who will then inform the maintenance department who will resolve repairs within 24 hours if the toilet repair can not be resolved within the program. |
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 observation, the facility failed to have a food preparation area with a refrigerator, stove, and an oven.
The findings include:
The physical plant inspection took place on June 1, 2012. At approximately 2:15 p.m. the kitchen was observed. The facility failed to provide a central food preparation area that included a stove, oven, and a refrigerator.
This finding was confirmed by the facility director.
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Plan of Correction
The stove, oven and range will be installed by the maintenance department (Asst Director of Building and Properties) and verified by the Program Director. Refrigerators will be installed the day of the move. |
705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
Based on the physical plant inspection, the facility failed to have a bedroom equipped with a mechanism for hearing impaired persons to be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system. Also, the bathroom designated for handicapped accessibility were not equipped with a mechanism for hearing impaired persons.
The finding include:
A physical plant tour was conducted on June 1, 2012 An interview with the facility director confirmed that 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 facility failed to have a client bedroom 24-D equipped with a strobe light or shaker bed to alert those with hearing impairment in event of a fire. Also, bathroom D-2 is the designated handicapped bathroom. This bathroom was not equipped with a mechanism for hearing impaired persons.
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Plan of Correction
A hearing impaired fire alarm mechanism was installed in the bedroom 24-D and in bathroom D-2 by the fire and security company who services and monitors the system. This was arranged by the Asst Director of Building and Properties and verified by the Program Director. |
705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on observation during the physical plant inspection, two fire extinguishers were not mounted properly.
The findings include:
The physical plant inspection took place on June 1, 2012. Two fire extinguishers were observed to be sitting on the floor. Fire extinguishers should be securely mounted on the wall. The fire extinguisher located in the kitchen and the fire extinguisher located in the hall, by room 27-D and the designated third exit were not mounted.
These findings were confirmed by the facility director and were not disputed.
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Plan of Correction
Two fire extinguishers will be mounted to the wall, one in the kitchen and one by Room 27-D, by the maintenance department (Asst Director of Building and Properties) and verified by the Program Director. Monthly inspections completed by assigned support staff will report to the PD any uninstalled fire extinguishers who will then contact the maintenance department to repair. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on observation during the physical plant inspection, the facility failed to ensure the confidentiality of client identity.
The findings include:
The physical plant inspection took place on June 1, 2012 between the hours of 2:00 p.m. and 3:30 p.m. During the physical plant inspection, the facility failed to ensure the confidentiality of the client's identity by failing to have window treatments or coverings in place. This allowed for outsiders to see in the facility and identify clients.
The facility had four emergency exits that were glass doors. All four doors failed to have window treatments in place.
There was a three panel window in the main lounge area of the facility that failed to have window treatments. This uncovered window permitted the potential for patients to be viewed by others not in treatment at the facility.
Additionally, the following client bedrooms failed to have window coverings, 16-D, 23-D, 27-D, and 28-D. The bathroom in 28-D also needed a window treatment.
The facility group room (11-D) failed to have window treatments.
The facility director confirmed these findings.
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Plan of Correction
Frosted window panes have been affixed to all 4 emergency exits, including internal doors that lead to other programs and the three panel window. This was completed by the maintenance department (Asst Director of Building and Properties) and verified by the Program Director. Four bedrooms cited in the report and bathroom 28-D will have either curtains or blinds installed by the maintenance department (Asst Director of Building and Properties) and verified by the Program Director. Draw curtains will be hung in the group room by the maintenance department (Asst Director of Building and Properties) and verified by the Program Director. Monthly inspections completed by assigned support staff will report to the PD any chipped or damaged blinds/curtains who will then contact the maintenance department to repair. |