INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on November 7, 2019 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site complaint investigation, Gaudenzia DRC Inc. 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential 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 in the physical plant tour, the facility failed to ensure that counseling session could not be seen. The door leading to the dining room where group counseling was taking place was open and clients could be seen.
This was discussed with facility staff during the complaint investigation.
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Plan of Correction
On the date of the inspection, 11/7/19. The door to the dining room where group was being held was closed after inspector completed her tour. Clinical Supervisor and Inpatient Director will review compliance of doors being closed during group in staff meetings. Clinical Supervisor and or Inpatient Director will conduct random group observation to ensure that doors are closed, where clients can not be seen or heard what is being discussed. |
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 the physical plant tour, the facility failed to have mattresses in good repair.
The flowing rooms had torn mattresses;
524
519
507
This was discussed with facility staff during the complaint investigation.
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Plan of Correction
During the time of the inspection, 11/7/19, the mattresses to rooms 524, 519 and 507 were replaced by maintenance staff. The Clinical Supervisor, Inpatient Director and Facility Maintenance Director will conduct weekly tours to ensure that there are no mattresses that are in need of repair. If repair is noted, the mattress will be replaced immediately by maintenance department. |
705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on the physical plant tour, the facility failed to ensure that bunk beds be equipped with a securely attached railing son each open side of the bunk in room, #714.
This was discussed with facility staff during the complaint investigation.
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Plan of Correction
On the date of the inspection, maintenance department replaced the missing bed rail on the bunk bed located in room 714. Residential Aide, Clinical Supervisor and or Inpatient Director will conduct daily tours of the rooms to ensure that the bed rails are on all bunk beds. |