INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 5, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Brookdale 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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705.6 (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 a physical plant inspection on April 5, 2022, the facility failed to provide either paper towels or a mechanical dryer in each client bathroom. These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Specific Course of Action: Brookdale will ensure paper towel are in each patient bathroom.
Means: Housekeeping staff will check patient rooms daily to ensure paper towels are replenished.
Responsible Parties: The Director of Housekeeping and or Director of Facilities will monitor patient rooms daily.
Facility is in full compliance as of April 7,2022. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential 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 physical plant inspection on April 5, 2022, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher companyThere were three fire extinguishers in the administration building, two fire extinguishers in the group lecture hall and one fire extinguisher in the kitchen that dated the last fire extinguisher inspection was on September 7, 2020. These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Specific Course of Action: Brookdale will ensure all fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
Means: The Facility Director or designee will create a list with the extinguisher location to confirm they are inspected and tagged by the Fire extinguisher company.
Responsible Parties: The Director of Facilities or designee will call a fire extinguisher company (Noakes fire systems) to inspect and tag all fire extinguishers yearly.
Facility will be in full compliance on 4/30/2022 |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a discussion with facility staff, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the projects drug and alcohol abuse services. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Specific Course of Action: Brookdale will obtain the services of an independent certified public accountant to perform an audit.
Means: The CFO will begin interviewing potential CPA's for conducting the required annual audit of Brookdale's financial activities. The fiscal audit will be scheduled as soon as possible in order to get into compliance with this standard.
Responsible Parties: The Chief Financial Officer will ensure an audit is completed annually.
Facility will be in full compliance on 12/31/2022 |