INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on October 7, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the investigation, BGI of Brandywine, 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 investigation and a plan of correction is required.
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Plan of Correction
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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
The facility failed to maintain all structures, fences and playground equipment to be free from danger to health and safety.
A physical plant inspection was conducted on October 7, 2020 which revealed the following deficiencies:
corrosion was observed on the three iron-frame staircases located outside of the Motel building, which created a potential safety hazard.
cement steps on theses staircases were cracking and broken in several place allowing water intrusion and hastening the corrosive activity on the metal structure.
structural metal beam, outside of room 21 near the breezeway, displayed signs of deterioration from water damage.
wooden beam outside of room 21 was rotted.
railings, and other exposed metal surfaces had peeling paint and were corroded.
was peeling paint on the wooden surfaces over the doors and on the window sills of the motel building.
metal picnic table adjacent to the recreation area behind the Mansion building was broken, which created a safety hazard.
perimeter fence in the rear of the Mansion building was in poor condition and had bent, broken and missing pickets and was leaning in several places indicating the need for repair.
wooden portico above the exit door from the barn on the southwest corner of the structure, has been damaged by boring insects and is in disrepair.
jagged metal pipe was found protruding form the pavement outside this exit door from the barn building, which created a trip and safety hazard.
short cinder block wall on the southeast corner of the barn building was shifted and the conduit pipe running along the bottom of the roof above this area was displaced.
dryer vents on the outer wall of the laundry room in the Motel building were broken with jagged plastic edges which created a safety hazard.
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Plan of Correction
The following deficiencies have been addressed:
* The metal picnic table was repaired as of 11/10/20.
* All 3 dryer vents in the motel laundry room were replaced as of 11/6/20.
* The perimeter fence repairs are scheduled to be completed by 12/11/20.
* The remaining deficiencies listed in this inspection report will be handled by outside contractors. We are working with our Corporate process to approve approval for the funds to complete this work. We anticipate having the work completed by 1/31/2021 weather permitting.
The Plant Operations Manager or designee will conduct weekly rounds for all buildings and the property and address any issues in a timely manner. Any potential repairs outside the scope of our internal maintenance team will be brought to the attention of the Program Director and CEO. The Program Director and/or CEO will conduct monthly inspections of all buildings and grounds to ensure continued compliance with this regulation. |
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
The facility failed to maintain the grounds of the facility in good repair for the safety of residents, employees and visitors.
A physical plant inspection was conducted on October 7, 2020 which revealed the following deficiencies:
laundry room in the Motel building was dirty and had trash and lint behind the appliances.
light cover in the laundry area contained insect carcasses and dirt.
dryer lint trap on the machine furthest from the door was broken.
was broken vinyl siding on the corner of the laundry room.
was evidence of water damage to the ceiling tiles or ceiling in rooms: 10, 14, 16, 17, 19, 20, 23, 27, 29 in the Motel. Additionally, there was evidence of water damage in the Mansion building in the following areas: ceiling in common area outside medication room, as well as the ceiling in the dining area.
cover on the air conditioning unit outside the clinical supervisor ' s office was broken and in poor condition.
screens throughout the facility were broken and in poor condition.
rooms #16, 27& 29 had water damage to the ceiling
room #23 had damage to the entrance door around the hasp.
rooms #22 & 24 had damage to the entrance door jamb which was split
water cooler in the lower level main room in the Mansion building was leaking onto the stone floor.
baseboard covers were missing, broken or rusted in the following areas:
oMotel rooms #16, 18
oMansion rooms #1, 3, 4, 5, 6, 7 & 8
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Plan of Correction
The following deficiencies noted during the 10/7/20 inspection have been completed or have the following timelines:
* Laundry room in motel was thoroughly cleaned on 11/6/20 and was witnessed as clean on 11/19/20.
* The light cover in the laundry room was cleaned on 11/6/20 and witnessed as clean on 11/19/20.
* All 3 dryer lint traps were replaced as of 11/6/20.
* Broken vinyl siding will be replaced by 12/1/20.
* Ceiling tiles with water damage in the following areas: rooms 10, 14, 16, 17, 19, 20, 23, 27, 29, in the mansion common area outside the medication room and in the dining room were all replaced by 11/17/20.
* The cover on the air conditioning unit outside the clinical supervisor's office will be addressed by 12/1/20.
* Window screens throughout the facility were replaced/repaired by 11/19/20.
* The hasp on motel room 23 was repaired by 11/13/20.
* Damage to the door jambs for motel room 22 and 24 was repaired on 11/18/20.
* A tray was placed under the water cooler to catch the overflow of water from the drip trap on 11/9/20.
* The baseboard covers in the following rooms were repaired and/or painted: 16, 18, 1, 3, 4, 5, 6, 7 and 8 as of 11/13/20.
The Plant Operations Manager or designee will conduct weekly rounds of the facility grounds and buildings and address any concerns within a reasonable timeframe. The Program Director will conduct monthly rounds to ensure ongoing compliance with this regulation. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential 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
The facility failed to 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.
A physical plant inspection was conducted on October 7, 2020 which revealed the following deficiencies:
trash cans in the lower breezeway between the Motel and the Mansion were not covered.
trash cans outside the barn courtyard and the trash can outside the detox adjacent to the walkway were uncovered.
trash cans in the kitchen and the dining area were not covered.
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Plan of Correction
All trash cans identified during the physical plant inspection on 10/7/20 in the lower breezeway, outside the Barn and Detox building and in the kitchen and dining area have lids as of 11/9/20 and during our inspection on 11/19/20. To ensure continued compliance our Plant Operations Manager or designee will secure all trash can lids during daily trash collection. |
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
The facility failed to provide ventilation in the following bathrooms:
room #22, 28
rooms #35, 36, 38, 40, 43, 44, 45, 46, 47, 48
bathroom #4
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Plan of Correction
The ventilation/exhaust fans were replaced in bathrooms 22, 28 and 4 on 11/17/20.
We have enlisted the help of our HVAC contracted vendor to determine the issue with the ventilation system in the Detox bathrooms. We anticipate a determination and repair to the HVAC system by 12/4/20.
To ensure compliance moving forward, the Plant Operations Manager or designee will conduct weekly maintenance rounds of all patient bathrooms and repair, clean or replace any broken exhaust/ventilation units. The Program Director will review the weekly documentation of the maintenance rounds and conduct monthly spot checks. |
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
The facility failed to maintain each bathroom in a clean and sanitary manner:
was evidence of mold in the following bathrooms: 11, 12, 14, 16, 17,1 8, 20, 21, 23, 25, 26, 27 in the Motel. Additionally, there was mold in the following rooms in the Detox building: 40, 41, 42, 43, 44 as well as the following rooms in the Mansion: bathrooms #1, 2, 4 & 5.
door was loose or inoperable in the following bathrooms: 13, 14, 26, 29.
were 4 exposed light sockets in the bathroom of Motel room #4 and the light socket in Motel room #25 bathroom was loose creating an arc hazard.
ventilation system ducts were broken or covered with dust in the following bathrooms:
oMotel rooms #24, 28
oDetox rooms # 36, 38, 47
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Plan of Correction
As of today 11/23 the following items have been addressed:
* Evidence of mold has been removed in the following bathrooms: 14, 16, 17, 40, 41, 1 and 2. The remaining rooms will be completed by 12/4/20.
* All the shower doors were repaired in 13, 14, 26 and 29 by 11/11/20.
* The exposed light sockets in room 4 and 25 were repaired by 11/13/20.
* The ventilation broken or covered in dust were repaired/cleaned in 24, 28, 36, 38 and 47 by 11/13/20.
The Plant Operations Manager or designee will conduct weekly maintenance checks of all patient bathrooms and repair, clean or replace any broken items. The Program Director will review the weekly documentation of the maintenance checks and conduct monthly rounds to ensure compliance. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
The facility failed to ensure that exits from the facility were unobstructed.
exit door from the barn building to the main courtyard was not functioning properly in that it could not be fully opened.
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Plan of Correction
The exit door was repaired on 11/18 and is currently functioning properly. The Plant Operations Manager will complete weekly building rounds to include exits and repair or replace any broken items. The documentation of the rounds will be reviewed at the monthly safety committee meeting to ensure compliance. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
The facility failed to ensure that exits from the facility were illuminated.
light fixture in the exit from the second floor of the Mansion was not functioning.
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Plan of Correction
The light bulb was replaced on 10/30 and this light fixture is not working correctly. The Plant Operations Manager or designee will complete weekly building rounds and repair or replace any broken items. The documentation of the rounds will be reviewed at the monthly safety committee meeting to ensure compliance. |