INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on September 5, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Alternative Counseling Associates, Inc. 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 review of the physical plan, it was determined that the facility failed to maintain the carpet on the stairway in a safe manner.
The findings were:
A review of the physical plant on September 6, 2012 at 10:30 a.m. revealed that the carpet on the stair case leading down the steps to the women's living quarters located in the lower level, had torn carpet on the steps and torn carpet on the landing of the staircase.
A discussion with the maintenance employee confirmed the condition of the carpet.
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Plan of Correction
The Executive Director assumes responsibility for this citation and the future monitoring of its compliance. Since this is a Health and Safety concern, we have obtained an estimate and the carpet will be installed within 30 days. This job will be completed by maintenance and supervised by Dr. Kot, Executive Director. |
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 which included inspection of mattresses and pillows throughout the facility as part of the onsite licensing inspection, the facility failed to ensure that all mattresses were in good condition.
The findings include:
Mattresses were randomly spot checked for cleanliness and good repair during the physical plant inspection. The mattresses were generally found to have green plastic covers. These mattresses were generally in worn condition. Tears were noted in mattress covers in each room on the second and third floor of the male dorms.
The maintenance employee confirmed the condition of the mattresses.
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Plan of Correction
The Executive Director assumes responsibility for this citation and the future monitoring of its compliance. We plan to replace 2 mattresses per month, for the next 6 months; replacing all of the needed mattresses by April 2013. We have a total of 13 mattresses to be replaced. This job will be completed by maintenance and supervised by Dr. Kot, Executive Director. |