INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and a complaint investigation conducted from August 29, 2011 to August 31, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection and investigation, Kensington Hospital 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential 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 residents, 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 physical plant inspection, the facility failed to keep the residential facility in good repair at all times.
Findings:
A physical plant inspection was conducted on August 29, 2011 at approximately 14:00 hours. A window pane in the five bed dormitory on the second floor of the building was held in place with duct tape.
The inspection was conducted with the facility director and the director of maintenance who verified the use of duct tape on a window in the five bed dormitory during the inspection on August 29, 2011.
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Plan of Correction
Due to damage from the recent hurricane, the broken window was removed and replaced with hard plastic. Replacement window is on order and should be installed by 10/15/11. The Facilities Director conducts daily environmental rounds on all hospital areas to assure compliance with the Department of Health Building Exterior and Grounds standards. The Director of Environmental Services is responsible for any non-compliance issues. |
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 a physical plant inspection, the facility failed to ensure that mattresses were in good repair. Five of ten mattresses were in need of replacement or repair.
Findings:
Mattresses were checked for cleanliness and good repair during the physical plant inspection on August 29, 2011 at approximately 14:00 hours. Five mattresses located in three rooms on the second floor were torn.
The physical plant inspection was conducted with the facility director and director of maintenance who verified five of ten mattresses were torn and in need of repair or replacement on August 29, 2011.
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Plan of Correction
All mattresses on the second floor have been replaced with new mattresses on 9/15/11. The Facilities Director conducts daily environmental rounds on all hospital areas to assure compliance with the Department of Health Sleeping Accommodation standards. The Director of Environmental Services is responsible for any non-compliance issues.
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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 observations during a physical plant inspection, the facility failed to provide a wall mirror in one of three bathrooms.
Findings:
A physical plant inspection was conducted August 29, 2011 at approximately 14:00 hours. The wall mirror in the three bed dormitory on the second floor was incapable of producing a reflection. The physical plant inspection was conducted with the facility director and director of maintenance who verified the condition of the wall mirror in the three bed dormitory on the second floor.
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Plan of Correction
The wall mirror in the three bed dormitory on the second floor has been replaced with a new wall mirror. Work was completed by the Hospital Maintenance staff on 9/15/11. The Facilities Director conducts daily environmental rounds on all hospital areas to assure compliance with the Department of Health Bathroom standards. The Director of Environmental Services is responsible for any non-compliance issues. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to provide an exhaust fan or window in one of three bathrooms.
Findings:
A physical plant inspection was conducted on August 29, 2011 at approximately 14:00 hours. The bathroom in the five bed dormitory on the second floor of the building did not have an operable fan.
The inspection was completed with the facility director and director of maintenance who verified the fan in the five bed dormitory was not operative.
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Plan of Correction
The exhaust fan in the bathroom in the five bed dormitory on the second floor was replaced by the Hospital Maintenance staff on 8/30/11. The Facilities Director conducts daily environmental rounds on all hospital areas to assure compliance with the Department of Health Bathroom standards. The Director of Environmental Services is responsible for any non-compliance issues. |