INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on May 21, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Gaudenzia, Inc., were partially substantiated. A plan of correction must be submitted by June 20/2010.
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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 tour of the physical plant and an interview with the facility director, the facility failed to keep the grounds of the facility clean, sanitary and in good repair at all times.
A tour of the facility was conducted on May 21, 2010 at 1:00 PM. During the tour, the inspector noted the carpet in the first floor hallway was visibly stained and in need of replacement.
An interview was conducted with the facility director prior to the physical plant tour. During this interview the facility director advised they were aware that the carpet was stained and needed to be replaced. The facility director stated that the carpet was scheduled to be replaced.
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Plan of Correction
The carpet was professionally cleaned on 6/20/10.
The Central Region Physical Plant Manager also met with the flooring vendor to secure measurements and select product style.
Installation of new flooring is expected within the next 3 months.
The Program Director will assume responsibility for following up with the Central Region Physical Plant Manager and Central Region Director regarding installation progress.
Targetd Completion Date: 9/30/10
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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 a tour of the physical plant and an interview with the facility director, the facility failed to keep the facility free of rodent and insect infestation.
The findings include:
A tour of the facility was conducted on May 21, 2010 at 1:00 pm. During the tour at approximately 1:30 pm, a bed bug was discovered on the underside of the mattress in bedroom # 16.
An interview was conducted with the facility director prior to the physical plant tour. During this interview the facility director advised they were aware of the bed bugs; and added the insect problem was under control but was not yet resolved.
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Plan of Correction
Room #16 was immediately treated with an approved chemical agent while licensing specialists were on site. The Central Region Physical Plant Manager (licensed exterminator)also subsequently treated the room.
The Program Director met with all clients on May 21,2010, and received no complaints of bedbugs. No complaints or incidents have occurred since.
The program will adhere to licensing regulations around the provision of a treatment facility that is free of rodent and insect infestation.
Program staff will adhere to all agency policies and protocols associated with pest control including bed bugs.
Program Director reviewed bed bug protocols with staff including but not limited to screening of client and client belongings, laundering of all clothing/shoes at admission, confiscation and sealed plastic storage of luggage, bags, etc..., handling of linens, room inspections, and immediate chemical treatment of sited bugs.
Ongoing room inspections are conducted twice daily by designated staff on duty and findings are documented in a log book.
Any bug findings are immediately reported to the Program Director who subsequently promptly reports such to the Central Region Director. The Central Region Director directs extermination services in collaboration with the Regional Physical Plant Manager.
Ongoing monitoring of protocol conformance is reported in daily logs and monthly reports completed by designated staff on duty and the Program Director then submitted to the QI and Safety Committees.
Targeted Resolution date: 6/24/10
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