INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on October 22, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, Gaudenzia - Fountain Springs 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 investigation and a plan of correction is due on November 27, 2007.
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Plan of Correction
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
The organization has permitted the use of heaters that are not permanently mounted or installed. During an inspection of the facility conducted on October 22, 2007 supplemental heaters that were not permanently mounted or installed were found in staff offices on the first floor.
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Plan of Correction
Supplemental heaters were removed from staff offices. Program Director inspected areas to ensure removal. |
705.10 (b) (5) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(5) Maintain automatic smoke detectors and fire alarms of a type approved by the Department of Labor and Industry or by the Underwriters Laboratories.
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Observations
The organization failed to maintain automatic smoke detectors in the physical plant. An inspection of the facility conducted on October 22, 2007 verified that "duct tape" had been applied to smoke detectors on the first floor, disabling the fire alarm system.
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Plan of Correction
"Duct tape" covering the smoke detectors has been removed. Program Director inspected areas to ensure removal. |
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
The licensee failed to notify the Department regarding an increase in client capacity. A review of a Gaudenzia Fountain Springs census report and an interview with management staff on October 22, 2007, revealed that the facility had exceeded the maximum capacity of twenty-four residents during the the period from October 1, 2007 through October 7, 2007.
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Plan of Correction
Facility will not exceed maximum capacity of twenty-four (24) residents. Intake Counselor and Clinical Supervisor will be instructed not to admit in excess of twenty-four (24) residents. Program Director will ensure compliance. |