INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on September 7, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Men & Women For Human Excellence, Inc. were substantiated. A plan of correction must be submitted by October 13, 2010.
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Plan of Correction
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705.21 (2) LICENSURE General req. for nonresidential facilities.
705.21. General requirements for nonresidential facilities.
The nonresidential facility shall:
(2) Have a certificate of occupancy from the Department of Labor and Industry or its local equivalent.
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Observations
Based on a review of the facility's Certificate of Occupancy, the Certificate failed to identify the applicable construction code edition.
The findings include:
The facility ' s Certificate of Occupancy was reviewed on September 7, 2010. The applicable construction code edition was not identified on the Certificate of Occupancy for the 2600 Cecil B. Moore Avenue building.
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Plan of Correction
The Clinical Director will contact the building code official and request that an applicable construction code edition be identified on the Certificate of Occupancy for the 2600 W. Cecil B. Moore Avenue building. Should the building code official choose not to accommodate the request, a letter the applicable construction code edition will be requested. Once the applicable construction code edition is received, the Clinical Director will forward it to the State. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a tour of the facility ' s physical plant, the facility failed to keep the grounds of the facility clean, safe and in good repair at all times for the safety and well being of clients, employees and visitors.
The findings include:
A tour of the facility ' s physical plant was conducted on September 7, 2010 at approximately 12:30 PM. The facility was required to be clean, safe and in good repair at all times. At the time of inspection, the 2600 Cecil B. Moore Avenue building was not in good repair.
The basement in this building was unfinished, dirty and in total disrepair. The ceiling and walls were missing plaster, and there were tools, ventilation ducts, wiring and other building materials scattered across the basement floor.
In Group Room B, the sink cabinet in the bathroom was damaged and missing a cover or trim for the kick plate.
In Group Room B, the storage room door had a hole that was approximately two inches wide.
The main exit door and door frame between Group Rooms A and B had scratches and peeling paint and needed to be repainted.
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Plan of Correction
Men & Women for Human Excellence currently utilizes only the First Floor of the building located at 2600 Cecil B Moore Ave. Clients, employees and visitors shall at no time have access to the second floor, third floor, or basement areas. To help ensure that compliance is maintained, the aforementioned areas shall be locked at all times and inspected several times during program days/evenings by maintenance workers to ensure compliance. Results of inspections shall be forwarded to the clinical director. Also, the clinical director will ensure that the grounds at the 2600 Cecil B Moore Avenue facility are kept clean, safe and in good repair at all times for the safety and well being of clients, employees and visitors. The clinical director will submit work orders to make repairs to the ceiling and walls of the basement. Also, the clinical director will conduct weekly inspections to ensure that all tools, ventilation ducts, wiring and other building materials are maintained in a safe and secure manner. Additionally, the Clinical Director has submitted a work request to repair/replace the cover for the kick plate in the bathroom sink cabinet located in Room B. Also, the hole in the storage room door in Room B has been scheduled for repair. And, finally, the main exit door and door frame between Group Rooms A and B have been repaired and painted. |
705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on a tour of the facility ' s physical plant, the facility failed to store all trash, garbage and rubbish in covered containers.
The findings include:
A tour of the facility ' s physical plant was conducted on September 7, 2010 at approximately 12:30 PM. The facility was required to store all trash, garbage and rubbish in covered containers. At the time of inspection, the trash cans located behind the 2600 Cecil B. Moore Avenue building were overflowing with trash, and trash was also piled beside the trash cans.
An interview with the clinical director was conducted on September 7, 2010 at approximately 2:00 PM. The clinical director confirmed that the trash was not stored in covered containers.
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Plan of Correction
Men & Women for Human Excellence will engage in daily inspections (during program hours) to ensure that all trash is stored in covered containers. MWFHE will purchase additional trash containers to accommodate the amount of trash and rubbish that accumulates during the week. Daily inspections by maintenance workers are to be conducted with reports of such inspections forwarded to the clinical director for review. |
705.23 (2) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on a tour of the facility ' s physical plant, the facility failed to maintain counseling areas with furnishings, which are in good repair.
The findings include:
A tour of the facility ' s physical plant was conducted on September 7, 2010 at approximately 12:30 PM. The facility was required to maintain counseling areas with furnishings, which are in good repair. In the 2600 Cecil B. Moore Avenue building, two of the chairs in the group room had tears in seating material.
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Plan of Correction
The Clinical Director will conduct weekly inspections of furniture in all counseling areas to confirm that such furniture is in good repair. When defected furniture is identified, it is to be immediately removed from the area until repairs are made and a report of such action is to be forwarded to the Clinical Director for further review. At the 2600 Cecil B. Moore Avenue building, the two damaged chairs have been removed and disposed of. |
705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential 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 a tour of the facility ' s physical plant, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom.
The findings include:
A tour of the facility ' s physical plant was conducted on September 7, 2010 at approximately 12:30 PM. The two bathrooms in the 2600 Cecil B. Moore Avenue building did not have individual paper towels or a mechanical dryer at the time of inspection.
An interview with the clinical director was conducted on September 7, 2010 at approximately 2:00 PM. The clinical director confirmed that the bathrooms did not have paper towels or a mechanical dryer.
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Plan of Correction
A house keeping person will conduct morning and afternoon inspections of all facility bathrooms to insure that individual paper towels are available for clients, employees, and visitors. Clinical director will assure that supplies are readily available to maintain compliance. The two bathrooms at 2600 Cecil B Moore Ave have been equipped with mounted paper tower holders and individual paper towels. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a tour of the facility ' s physical plant, the facility failed to prohibit the use of heaters that are not permanently mounted or installed.
The findings include:
A tour of the facility ' s physical plant was conducted on September 7, 2010 at approximately 12:30 PM. The facility was required to prohibit the use of heaters that are not permanently mounted or installed. A portable space heater was observed in a closet in the 2600 Cecil B. Moore Avenue building.
An interview with the clinical director was conducted on September 7, 2010 at approximately 2:00 PM. The clinical director confirmed that a portable space heater was observed in the closet.
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Plan of Correction
Men & Women for Human Excellence will prohibit the use of heaters that are not permanently mounted or installed. Any such heaters will be immediately removed from the facility. Periodic inspections (twice per week) are to be conducted by Clinical Director to detect any action contrary to this regulation. Upon further investigation and inspection by the Clinical Director, it has been determined that the item at 2600 W Cecil B Moore Ave, initially identified as a heater, is in fact a cooling fan.
Additionally, the Clinical Director has removed the portable space heater from the storage closet in group room B. |
705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on a tour of the facility ' s physical plant, the facility failed to maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet
The findings include:
A tour of the facility ' s physical plant was conducted on September 7, 2010 at approximately 12:30 PM. The facility was required to maintain a minimum of two exits on every floor. The facility did not provide an alternate exit for the basement in the 2600 Cecil B. Moore Avenue building.
An interview with the clinical director was conducted on September 7, 2010 at approximately 2:00 PM. The clinical director reported that the basement is not used and was supposed to be locked, but it was not locked at the time of inspection.
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Plan of Correction
Men & Women for Human Excellence provides services for consumers only on the first floor of the building at 2600 Cecil B Moore Ave. The remaining areas of the building are off limits for MWFHE clients, employees, and visitors. A pad lock is now in place on the door leading to the basement in order to prevent access by the aforementioned persons. Should MWFHE decide to use the basement portion of the facility in the future, an application for a Certificate of Occupancy will be submitted subsequently to making necessary repairs and reconfigurations of the area in question. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
Based on a tour of the facility's physical plant, the facility failed to maintain each stairway exceeding two steps with a well secured handrail.
The findings include:
A tour of the facility ' s physical plant was conducted on September 7, 2010 at approximately 12:30 PM. The facility was required to maintain each stairway exceeding two steps with a well secured handrail. The basement stairs in the 2600 Cecil B. Moore Avenue building did not have a handrail.
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Plan of Correction
Men & Women for Human Excellence provides services for consumers only on the first floor of the building at 2600 Cecil B Moore Ave. The remaining areas of the building are off limits for MWFHE clients, employees, and visitors. A pad lock is now in place on the door leading to the basement in order to prevent clients, employee, and/or visitors from gaining access. Inspections will be conducted, regularly, to confirm that ongoing restriction of the area in question is maintained. Results of inspections are to be forwarded to the Clinical Director for review. Additionally, the Clinical Director will submit a work order for the installation of a handrail along the basement stairway at the 2600 Cecil B Moore Ave location. |
705.28 (b) (2) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(2) Place the smoke detector in a common area or hallway. All detection devices shall be interconnected.
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Observations
Based on a tour of the facility's physical plant, the facility failed to maintain a minimum of one operable smoke detector on each floor, including the basement and attic.
The findings include:
A tour of the facility ' s physical plant was conducted on September 7, 2010 at approximately 12:30 PM. The facility was required to maintain a minimum of one operable smoke detector on each floor, including the basement and attic. The Facility must provide documentation that there is an operable smoke detector in the basement of the 2600 Cecil B. Moore Avenue building.
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Plan of Correction
Clinical Director Will make arrangements for the installation of a smoke detector in the basement area of the building located at 2600 Cecil B Moore Ave. The Facility will provide documentation that there is an operable smoke detector in the basement. |
705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential 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, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a tour of the facility ' s physical plant, the facility failed to maintain a portable fire extinguisher on each floor.
The findings include:
A tour of the facility ' s physical plant was conducted on September 7, 2010 at approximately 12:30 PM. The facility was required to maintain a portable fire extinguisher on each floor. The facility provided three fire extinguishers in the 2600 Cecil B. Moore Avenue building, but the extinguishers were not wall mounted.
In addition the facility must provide documentation that there is a type ABC Fire Extinguisher in the basement with a current inspection.
An interview with the clinical director was conducted on September 7, 2010 at approximately 2:00 PM. The clinical director confirmed that the fire extinguishers were not wall mounted.
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Plan of Correction
The Clinical Director submitted a work order to mount the three fire extinguishers on the first floor of the 2600 W Cecil B Moore Ave location. The work was completed on September 8, 2010. Also, The Clinical Director submitted a work order to mount a type ABC Fire Extinguisher in the basement at the same location with a current inspection ticket. Installation is to be completed by 10/22/2010, at which time documentation of the completed work will be availabe.
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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a tour of the facility ' s physical plant, the facility failed to ensure that all fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
The findings include:
A tour of the facility ' s physical plant was conducted on September 7, 2010 at approximately 12:30 PM. The facility was required to ensure that all fire extinguishers are inspected annually. In the 2600 Cecil B. Moore Avenue building, the inspection tag on one of the three fire extinguishers had an inspection date of June 2008.
An interview with the clinical director was conducted on September 7, 2010 at approximately 2:00 PM. The clinical director confirmed that the identified fire extinguisher had an inspection date of June 2008.
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Plan of Correction
The Clinical Director will ensure that all fire extinguishers are inspected annually. At the 2600 Cecil B Moore location,the Clinical Director removed the fire extinguisher with the inspection date of June, 2008 and replaced it with one that has an inspection date of March, 2010 |