INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 6, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection UNP46701 One Day at a Time 1 was found to not be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Therefore, deficiencies were identified during this inspection and a plan of correction is required.
|
Plan of Correction
|
§ 717.29(b)(1) LICENSURE Physical plant standards - Bldg-Exterior-Grnd
§ 717.29. Physical plant standards.
(b) Building interior, exterior and grounds. The licensee shall:
(1) Keep the interior, exterior, and grounds or yard of the drug and alcohol recovery house clean, safe, sanitary and in good repair and free of hazards at all times.
|
Observations
Based on the physical plant inspection the recovery house failed to ensure that the interior of the drug and alcohol recovery house in good repair.
Findings: Leaks in ceiling throughout building, and dressers are broken.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
Plan of Correction: Physical Plant Standards -Bldg.-Exterior-Grnd.
The ODAAT Team has implemented the procedure on 03/07/2024 according to $717.29 Licensure.
The ODAAT Team will immediately notify ((Lead Supervisor, Directors and Designated Qualified Staff) responsible for contracting repairs for ODAAT sites.
Building owner responsible for facility upkeep and repairs had contractors begin repairs on March 10, 2025. Repairs are still in progress with an estimated completion date of April 7, 2025
Lead Supervisor will use the proper documentation set in place by the ODAAT Team to report and submit maintenance request for all needed repairs for the site.
The House Manger (Alita Mapp) will follow up with staff and building owner responsible for repairs to have accurate updates of repair progress and completion.
Lead Supervisor will use the proper documentation set in place by the ODAAT Team to report and submit the replacement of all damaged furniture in bedrooms and lounge areas.
ODAAT Team will implement the process of obtaining and replacing broken dressers on site on 3/24/2025
The House Manager(Alita Mapp) will keep track of ,furniture orders placed and delivery time to sites with ODAAT Teams account payable department.
|
§ 717.29(e)(5) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
|
Observations
Based on the physical plant inspection the recovery house failed to ensure that bathrooms has operating exhaust systems.
Findings: Resident bathrooms do not have operating exhaust system.
These findings were reviewed with the recovery house staff during the licensing process
|
Plan of Correction
Plan of Correction: Physical Plant Standards -Bldg.-Exterior-Bathroom.
The ODAAT Team has implemented the procedure on 03/07/2024 according to $717.29 Licensure.
The ODAAT Team will immediately notify ((Lead Supervisor, Directors and Designated Qualified Staff) responsible for contracting repairs for ODAAT sites.
Building owner responsible for facility upkeep and repairs had contractors begin repairs on March 10, 2025. Repairs are still in progress with an estimated completion date of April 7, 2025
Lead Supervisor will use the proper documentation set in place by the ODAAT Team to report and submit maintenance request for all needed repairs for the site.
The House Manger(Alita Mapp) will follow up with staff and building owner responsible for repairs to have accurate updates of repair progress and completion.
|
§ 717.31(c)(4) LICENSURE Unusual incidents - 3-day Filing
§ 717.31. Unusual incidents.
(c) The licensee shall file a written unusual incident report with the Department within three business days following an unusual incident involving:
(4) An event at the drug and alcohol recovery house requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on review of the resident records the licensee failed to file an unusual incident with the Department within 3 business days following an unusual incident involving an event at the drug and alcohol recovery house requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
Plan of Correction: Unusual Incidents ? 3 Day Filing
The ODAAT Team has implemented the procedure according to $717.31©(4) on 03/07/2025 Licensure that all incidents that occur onsite or off site will be documented on an incident report form any time there is the need for police, EMT or fire personnel to intervene.
ODAAT staff will provide necessary information needed to medical, law or fire departments according to federal, state and local confidentiality laws to assist with cities or needed intervention at the time of incident.
Immediate next steps ODAAT staff (Lead Supervisor, Directors and Designated Qualified Staff)(Alita Mapp) will immediately notify SCA and then notify DDAP within 3 days through the provided(ERS) portal as an Unusual incident.
|