INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the October 19, 2011 licensure renewal inspection. The follow-up inspection was conducted on October 7, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Gaudenzia DRC 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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705.6 (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 on a physical plant inspection, the facility failed to provide slip-resistant surfaces in all bathtubs and showers.
The findings include:
A physical plant inspection was conducted on October 7, 2011 at approximately 6:00 AM. The facility did not provide slip-resistant surfaces in all bathtubs and showers.
The shower in client bedrooms # 704, 707, 710 and 714 did not have slip-resistant surfaces.
Additionally, the showers in the communal bathrooms on the 7th floor women ' s unit did not have slip-resistant surfaces.
An interview with the project director on October 7, 2011 confirmed the findings.
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Plan of Correction
A physical plant inspection was conducted on October 7, 2011 at approximately 6:00am. The facility did not provide slip-resistant surfaces in all bathtubs and showers.
On October 7, 2011 the facility installed slip-resistant surfaces in all bathtubs and showers. This occurred while the auditor was in the facility.
The operations director and/or maintenance supervisor will monitor the bathrooms daily to ensure compliance of policy 705.6.(4) Bathrooms.
Persons Responsible:
Inpatient Director
Operations Director
Maintenance Supervisor
Timeframes for Completion: January 7, 2012
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709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a physical plant inspection, the facility failed to notify the Department within 90 days of the occurrence of a change in the authorized client capacity.
The findings include:
A physical plant inspection was conducted on October 7, 2011 at approximately 6:00 AM. The facility's authorized maximum capacity for Inpatient Non-Hospital clients is 48. At the time of inspection the total number of beds observed was 44.
There were 14 beds on the 7th floor women ' s unit:
Room # 704 = 2 beds
Room # 707 = 2 beds
Room # 708 = 2 beds
Room # 709 = 2 beds
Room # 710 = 2 beds
Room # 711 = 2 beds
Room # 714 = 2 beds
There were 30 beds on the 5th floor men ' s unit:
Room # 501 = 2 beds
Room # 502 = 2 beds
Room # 503 = 2 beds
Room # 504 = 2 beds
Room # 505 = 2 beds
Room # 506 = 2 beds
Room # 507 = 2 beds
Room # 508 = 2 beds
Room # 509 = 2 beds
Room # 511 = 2 beds
Room # 517 = 1 beds
Room # 519 = 2 beds
Room # 521 = 2 beds
Room # 522 = 2 beds
Room # 523 = 2 beds
Room # 524 = 1 beds
The facility did not notify the Department of this change in the authorized client capacity.
An interview with the project director on October 7, 2011 confirmed the findings.
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Plan of Correction
A physical plant inspection was conducted on October 7, 2011 at approximately 6:00am. The facilities authorized maximum capacity for Inpatient Non-Hospital clients is 48. At the time of inspection the total number of beds observed was 44.
On October 7, 2011 the 4 beds were returned to the Inpatient Non Hospital Program and the total number of beds was brought back to 48.
If the facility decides to change the maximum authorized capacity of 48 beds in the Inpatient Program, the Director will notify DOH within 90 days.
The daily roster and bed sheet will be used to monitored daily to ensure compliance of policy 709.14 (b)(5).
Persons Responsible:
Division Director
Inpatient Director
Operations Director
Inpatient Clinical Supervisor
Timeframes for Completion: January 7, 2012
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