INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on November 15, 2019 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site complaint investigation, ADAPPT House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
The facility failed to ensure that the exterior grounds were maintained and free from danger to health and safety.The sidewalk in front of the building along Madison Avenue where the secure entrance is located is cracked and broken which created a trip hazard. The facility plan of correction from the March 28, 2019 survey stated that they would have the contractor repair the sidewalk by June 7, 2019, however this was not implemented at the time of the inspection.
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Plan of Correction
On November 23, 2019, repair to the Madison Avenue sidewalk has been removed and aggregate has been laid down. Concrete has been poured and side walk has been repaired. Monitoring staff will inspect side walk daily for any damages and report to the Director of Facility.
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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
The facility failed to ensure that the facility was free from danger to health and safety of clients, staff and visitors.There was a water spigot protruding into the path of egress, on the exterior stairs from the wall at the exterior exit stairs, from the men's wing to the parking lot near Madison Avenue. The facility plan of correction from the March 28, 2019 survey stated that they would have the plumber move the spigot by April 26, 2019, however this was not implemented at the time of the inspection.
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Plan of Correction
On November 15, 2019, facility maintenance installed a handrail which covers the water spigot from protruding into the path of egress from the exterior stairs on the exterior wall of the men's wing near Madison Avenue. The spigot is no longer a safety issue. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
The facility failed to ensure that the exterior exits from the facility was unobstructed.The exit from the female wing to the parking lot had a large rodent trap on the third stair from the top landing which created a trip hazard.This information was shared with facility staff in order to correct the dangerous condition.
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Plan of Correction
On November 15, 2019 at time of inspection, the rodent trap was removed from the stairs. Additionally, the facility director provided direction to the pest control company not to place rodent trap boxes on stairwell. Also, as of November 15, 2019, during daily perimeter checks, security staff are conducting inspections of stairwells to confirm rodent trap boxes are not being placed on stairs to ensure that the exterior exits from the facility are unobstructed in the rounds report. Any damages will be reported to the Facility Director |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to protect the confidentiality of client records.The administration building at 428 Walnut St. had unattended client identifying information sitting on a desk. The door from Walnut street to this area was unlocked allowing access to this area that was unmonitored at the time of the investigation. This information was shared with facility staff in order to correct the condition.
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Plan of Correction
Client identifying information has been removed from the front desk in the administration building on 11/15/19 (date of DDAP visit.) Facility Director will monitor this area daily for compliance |