INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on August 20, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Gaudenzia, Inc. Broad Street 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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705.2 (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 August 20, 2024, the facility failed to maintain the grounds in good repair at all times for the safety and well-being of residents, employees and visitors.
Rm # 408 was observed to have loose floor tiles which is a tripping hazard.
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Plan of Correction
Work Order submitted for Room 408 loose floor tiles to be repaired with next two weeks and no later than9/4/2024. To prevent future violations Director will conduct biweekly room inspections' to ensure no rooms are in need of repair. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of internal incident reports, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving an event requiring the presence of ambulance personnel.
On 6/2/24, EMS were onsite to transport a resident to the hospital. The facility did not submit a written unusual incident report to the Department.
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Plan of Correction
Director failed to submit incident report. in order to prevent further occurrence tracking sheet will be used during daily meetings to ensure any needed documentation has been submitted in timely manner this has been implemented effective 9/3/2024. |