INITIAL COMMENTS
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This report is a result of an on-site relocation licensure inspection conducted on 11/28/2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, Genesis House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is required.
As this was the initial relocation inspection conducted, not all regulations were reviewed. During future inspections, all regulations will be reviewed for compliance.
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Plan of Correction
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a relocation inspection conducted on 11/28/2023, the facility failed to ensure that the counseling sessions cannot be seen outside the counseling room.
- The 2nd floor counselor office across from the elevator was missing a window covering.
- The 3rd floor group room was missing window coverings on two standard windows and the flower shaped window.
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Plan of Correction
Based on a relocation inspection conducted on 11/28/2023, Genesis House, Inc. failed to ensure that the counseling sessions cannot be seen outside the counseling room.
The 2nd floor counselor office across from the elevator now has curtains hung in the office to ensure privacy and confidentiality.
The 3rd floor group room, now has coverings for all windows in the room including the clover shaped window in that room to ensure privacy and confidentiality.
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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential 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 relocation inspection conducted on 11/28/2023, the facility failed to ensure that the fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
The inspection tags were missing from all of the fire extinguishers on the three floors of the building.
This was discussed with facility staff during the relocation inspection.
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Plan of Correction
Based on a relocation inspection conducted on 11/28/2023, Genesis House, Inc. failed to ensure that the fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
The landlord of the building was contacted and he ensured that the fire extinguishers are mounted on each floor in an accessible location, inside of a mounted case on the wall. He also ensured that the fire extinguishers have been appropriately tagged prior to mounting. |