INITIAL COMMENTS
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This report is a result of an onsite physical plant inspection conducted on September 12, 2017 by staff from the Division of Program Licensure for the licensure renewal. Based on the findings of the inspection, North Philadelphia Health System Goldman Clinic was found to be out of compliance 28 Pa. Code chapter 705.21 Physical Plant Standards. Because this was just a physical plant inspection not all regulations were looked at during this inspection. The facility has the following deficiencies:
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Plan of Correction
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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
Based upon observation on September 12, 2017, the facility failed to ensure that all trash, garbage and rubbish was stored in covered containers that prevent the penetration of insects and rodents.
The findings include the following:
The facility had a trash compactor; however, at the time of the inspection there was trash that had not been compacted sitting on top of the compactor. Upon operating the compactor, the trash was then inside the compactor, but, there was a missing piece that would make it a closed unit. The compactor had an opening the entire width of the unit that would allow for penetration of rodents and/or insects.
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Plan of Correction
The Director of Environmental Services will contact the trash company regarding the repair of replacement of the current trash compacted so that no space exist when closing the compactor. This will take place on or before October 28,2017.
To monitor and ensure that this deficiency does not recur the department supervisor will inspect the area on a weekly basis, and report any needed repairs to the Director. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based upon observation on September 12, 2017, the facility failed to ensure that showers were provided with slip resistant surfaces.
The findings include the following:
The following bathrooms lacked slip resistant surfaces for showers:
Room 450
Room 453
Room 463
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Plan of Correction
The Director of Facilities management will have slip resistant decals placed on the shower floors of all rooms on or before October 20, 2017.
To monitor and ensure that this deficiency does not recur the floor staff will conduct weekly environmental rounds and report needed repairs to the maintenance department |
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 upon observation on September 12, 2017, the facility failed to ensure that the bathrooms were ventilated by operable exhaust fans or operable widows.
The findings include the following:
The following bathroom exhausts were not working at the time of the inspection and there were no operable windows in the bathrooms:
Room 425
Room 425 Bathroom at lounge near room 404
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Plan of Correction
The Director of Facilities management will have the motors repaired in all bathrooms on or before October 28, 2017
To monitor and ensure that this deficiency does not recur the floor staff will conduct weekly environmental rounds and report needed repairs to the maintenance department |
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
Based upon observation on September 12, 2017, the facility failed to ensure that the bathrooms were maintained in a functional, clean and sanitary manner at all times.
The findings include the following:
The bathroom door jamb for the shared bathroom of room 453 was rusted and crumbling.
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Plan of Correction
The Director of Facilities management will replace/repair the door jam on or before October 28, 2017.
To monitor and ensure that this deficiency does not recur the floor staff will conduct weekly environmental rounds and report needed repairs to the maintenance department |