INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on November 10, 2014, by staff from the Department of Drug and Alcohol Programs, Division of Program Licensure. Based on the findings of the on-site licensing inspection, Gaudenzia Together House 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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705.2 (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
Based on a physical plant inspection conducted on November 10, 2014 between 12:00pm and 3:00pm, it was determined that the facility failed to 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 findings were:
A physical plant inspection was conducted and the the following safety and sanitary issues were observed:
1. Bedroom 807 had a large amount of dust collecting on the mechanical ventilation covers.
2. Bedroom 802 - Missing window treatements and the light fixtures were stained.
3. Bedroom 807 - Window treatment was in disrepair above Bed D.
4. Bedroom 803 - There were missing window treatments and stained light fixtures.
5. Dirt and debris was found on the floor of the janitorial closet, which is across from the nurse ' s station on the 2nd floor.
6. There were many escutcheon plates (which go around the sprinkler heads) missing throughout the entire building on all floors inspected.
7. There were several drawers in the front nurse ' s station that were falling apart and needed to be replaced/fixed.
These findings were discussed with facility staff during the complaint investigation process.
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Plan of Correction
The Maintenance Department cleaned all ventilation covers on the 8th floor on 12/3/14.
The window treatments in rooms #802, #807, and #803 were replaced and stained light fixtures were cleaned on 12/3/14.
Dynamo Cleaning cleaned the dirt and debris in the 2nd floor janitorial closet on 11/24/14.
Majek Fire Protection will start replacing the escutcheon plates throughout the facility by 12/11/14.
The drawers in the nurses station were repaired on 12/5/14.
The residential facility will be monitored daily per DDAP Policy 705.2 Building Exterior and Grounds.
Persons Responsible: Program Director, Operations Supervisor, Maintenance Department, House Manager of Maintenance.
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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 observation and a physical plant inspection, the facility failed to provide a bed with solid foundation and fire retardent mattress in good repair.
The findings include:
A physical plant inspection was completed on November 10, 2014. Bedroom 807 had 5 beds located in the room. 2 of the bed's mattress covers were dirty and needed to be replaced.
These findings were reviewed with facility staff during the complaint investigation process.
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Plan of Correction
Mattress covers were purchased and replaced on the 2 beds in Room #807 that was identified during the DDAP Audit.
The residential facility bedrooms will be toured daily to meet the DDAP Policy 705.5(a) Sleeping Accommodations.
Persons Responsible: Program Director, Operations Supervisor, Maintenance Department, House Manager of Maintenance.
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on observation during the physical plant inspection, the facility failed to provide an operable soap dispenser in the facility's bathrooms.
The findings include:
A physical plant inspection was completed on November 10, 2014 between 12:00pm and 3:00pm. The following bathrooms did not have an operational soap dispenser or did not have soap in the dispenser:
1. In bedroom 202/204's shared bathroom, there was a soap dispenser, but it was non-operational.
2. In bedroom 206's bathroom, there was a soap dispenser hanging on the wall; however, there was no soap in the dispenser.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The soap dispenser in Bedroom #202/#204 has been replaced.
The soap dispenser in Bedroom #206 was refilled on the day of the DDAP Audit.
The unit bathrooms will be monitored daily to meet the expectations of DDAP Policy 705.6 (2) Bathrooms.
Persons Responsible: Program Director, Operations Supervisor, Maintenance Department, House Manager of Maintenance.
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705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on the physical plant inspection, the facility failed to ensure that it was free of rodent and insect infestation at all times.
The findings include:
During a physical plant inspection conducted on November 10, 2014, bedroom numbers 803 and 804 were observed to have an unusual amount of live flies in them.
These findings were reviewed with facility staff during the complaint investigation process.
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Plan of Correction
Ehrlich Pest Control exterminated the facility, which included Bedrooms #803 and #804, for gnats and flies on 11/13/14.
Gaudenzia has a monthly contract with Ehrlich Pest Control to exterminate. Their next visit is scheduled for 12/ 11/14.
The unit will be monitored daily for pests per DDAP Policy 705.9 (1) General Safety and Emergency Procedures.
Persons Responsible: Program Director, Operations Supervisor, Maintenance Department, House Manager of Maintenance.
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