INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 9, 2016, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Focus 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
The physical plant inspection was conducted on May 9, 2016.
Based the physical plant inspection the facility failed to keep the facility grounds clean and sanitary. The refrigerator in the medication room used to store a client's Haloper Dec 100mg medication, had a dirty interior, and the gasket sealing the refrigerator door had several patches of visible mildew.
Based the physical plant inspection the facility failed to keep the facility grounds in good repair at all times. The wooden bench built into the wall located at the rear right corner of bedroom #3 was missing a rectangular section of its seat approximately 1 foot wide and 4 feet long.
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Plan of Correction
On May 9, 2016 Refrigerator in Medication Room was cleaned and sanitized by House Manager. In order to prevent the recur of deficiency refrigerator in Medication Room used to store client's medications (Haloper Dec 100mg)House Managers will clean interior and gasket sealing on refrigerator door once weekly. Program Director will inspect Medication Room Refrigerator bi-Weekly to ensure refrigerator and refrigerator door will be free of any visible signs of mildew.
On 6/13/2016 Gaudenzia Maintenance Department will come to the facility to repair/replace the rectangle section of the wooden bench built into wall in room 3 approximately 1 foot long and 1 foot wide. |
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
The physical plan inspection was conducted on May 9, 2016.
Based on the physical plant inspection the facility failed to ensure that the hot water temperature in the bathrooms did not exceed 120 degrees Fahrenheit. The hot water temperature for the basement bathroom had a tested temperature of 127.5 degrees Fahrenheit at 2:46PM.
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Plan of Correction
On 6/13/2016 Gaudenzia's Maintenance Department will dial down the water tank. To ensure that deficiency does not recur House Managers will test water temperature and document water temperature results in Communication Log Book once weekly to ensure that the facility's basement bathroom water temperature does not exceed 120 degrees Fahrenheit. Program Director will review Communicated documentation of water temperature results and test water temperature bi-weekly to ensure water temperature in basement bathroom does not exceed 120 degrees. Fahrenheit. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
The physical plant inspection was conducted on May 9, 2016.
Based on the physical plant inspection the facility failed to ensure that the exits from the residential facility were unobstructed. The door for exit B leading outside of the facility was stiff and difficult to open.
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Plan of Correction
On 6/13/2016 Gaudenzia's Maintenance Department Crew will come out to make certain that Exit Door B leading outside residential Facility is unobstructed and not stiff and difficult to open. To ensure deficiency does not recur Gaudenzia's Maintenance Department will visit facility once monthly to make sure Exit Door B leading outside stay unobstructed, easy and effortless to open. |