INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 11, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, LZUK6701 DePaul House 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 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.
Fidnings: Light fixtures through out the house did not have protecive covers over bulbs.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
As this is a safety hazard to both staff and residents. To avoid recurrence The grounds in the back and sides of the outside of the plant are being trimmed and pruned and passage ways made clear every week when the maintenance crew cuts the grass for DePaul House.
The landscaping for the unmaintained area of the outside parts of DePaul has started immediately. As in the first weather permitting day of the week following 6/14. Landscaping is performed weekly and those areas mentioned in the report are part of maintenance.
The Maintenance Coordinator with monitor as he does with all chores at the end of day to ensure all steps/measure have been taken to keep the grounds clear and safe for all.
For the lightbulbs I was under the impression a simple switching of lightbulbs would fix the issue as I had new bulbs ordered. However the entire canisters will have to be removed and new light fixtures installed. That will take several month to complete and correct the issue.
The exposed bulbs nearest to the emergency exits have been corrected with new covers as those are different types of ceiling lights and easy to correct.
The correction of the remaining expose bulbs will begin approximately from the last week of August and estimated to be completed by October of 2026. I am leaving room for error/unforeseen issues that may arise during repairs/replacements.
As this is a safety hazard DePaul will do our best to complete all repairs before or by October of 2026. |
§ 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 maintain operable ventilation in the bathroom.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
Per the visit, there was a large window in the bathroom to the left of the bathroom that was obstructed by many packages.
Those packages have been removed and there is now airflow in the bathroom.
this was done immediately following the inspection.
If the fan still needs to be replaced. Please let me (Christelle) know and I will place a service order to have the exhaust fan replaced. This correction would be started immediately and completed by the end of August.
The Maintenance Coordinator would be in charge of completing the project and assigning monthly checks to all of the bathroom fans/windows at DePaul House. Repairs would be performed as needed within a week of findings.
|
§ 717.29(g)(1) LICENSURE Physical plant standards - Heating-Cooling
§ 717.29. Physical plant standards.
(g) Heating and cooling. The licensee:
(1) Shall maintain an indoor temperature in the drug and alcohol recovery house between 65°F and 90°F at all times.
|
Observations
Based on the physical plant inspection the recovery house failed to maintain 3rd floor indoor temperature at a comfortbale degree.
|
Plan of Correction
DePaul's Maintenance Coordinator will make monthly appliance checks. This will ensure that all appliances including the air conditioners are working at full capacity.
For this particular incident, the air conditioner in room 14 was replaced on 7/22. The 3rd floor now has all rooms functioning with working appliances which is keeping the floor at a comfortable temperature. A picture will follow.
There is an industrial fan in the hallway to help circulate the stagnant air. It is larger and more efficient than the previous fan.
During the maintenance checks, the MC will ensure are appliances are working at their full capacity; but order and replaces appliances/ parts as needed within 42hrs of discover. 42hrs to order and repairs/installs will have been made within 5 days of discovery.
In the event an issue is reported/discovered by someone other than the MC, We have work orders dedicated to these matters. This will insure DePaul doesn't miss anything.
|
§ 717.29(g)(2) LICENSURE Physical plant standards - Heating-Cooling
§ 717.29. Physical plant standards.
(g) Heating and cooling. The licensee:
(2) May not use or permit portable space heaters.
|
Observations
Based on the physical plant inspection the recovery house failed to check for portable space heaters.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The Residential Aids will be responsible for a weekly check of the residents rooms to insure there are no portable space heaters or any other prohibited items in their rooms.
June 29th were the first of the room checks specifically targeting prohibited items/appliances in the room.
DePaul has made flyers with the prohibited items and has them posted throughout the building.
The flyer will be included in the DePaul handbook and distributed to the residents.
Space heater has been removed from the residents room. All remaining rooms where checked for prohibited items. |
§ 717.30(b)(2) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(2) Maintain a minimum of two unobstructed exits that are separated by a minimum distance of 15 feet on every floor that contains resident bedrooms. Equipment such as ladders and escapes located above the ground floor must be securely affixed to the house. Rooms, including resident bedrooms, that contain an exit must be unlocked and accessible to all residents in the event of an emergency.
|
Observations
Based on the physical plant inspection the recovery house failed to maintain a securly mounted ladder leading from a bedroom in room 16 on the third floor.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
DePaul House Maintenance Coordinator has secured ladder on the 3rd floor in room 16.
To Prevent recurrence MC will include ladder checks when performing our monthly fire drills.
A picture of secured ladder will be provided. |