INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 23, 2016, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. Harrisburg Concept 90 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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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the onsite inspection of the physical plant conducted on May 23, 2016, the facility failed to ensure that water temperatures in the facility bathrooms did not exceed 120 degrees Fahrenheit.
The hot water temperature in the women's shower room was tested at 133.0 degrees Fahrenheit at 3:36 PM.
The hot water temperature in the men's shower room was tested at 125.1 degrees Fahrenheit at 4:00 PM.
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Plan of Correction
The hot water system in the facility is controlled by DGS (State facility grounds). The Central Region Maintenance Director contacted DGS to adjust the electrical hot water unit to maintain temperature at its 120 degree capacity. This was completed as of 5/30/2016.
The Program Director will obtain infra red water temperature gun and institute weekly checks to be documented on weekly maintenance report.
Program Director will review and sign off on weekly reports to assure correct temperature is maintained.
This will be completed by June 30th, 2016. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on the onsite inspection of the physical plant conducted on May 23, 2016, the facility failed to ensure that all bathtubs and showers had slip-resistant surfaces.
The first shower on the left in the women's shower room did not have a slip-resistant surface.
The middle shower in the men's shower room did not have a slip-resistant surface.
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Plan of Correction
Additional shower mats will purchased for women's and men's shower by the Program Director and Central Region Maintenance Director.
Central Region Maintenance Director Ordered mats and will be received and placed in shower areas by 6/30/2016.
Daily facility checks will maintain shower mats placement in shower areas by house manager support staff during daily cleaning runs.
Program Director or Clinical supervisor will review safety reports, weekly and monthly maintenance reports to implement corrective measures when needed. |