INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 18, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Gaudenzia Erie Inc. - Crossroads 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 tour, during the compliant investigation, conducted on May 18, 2021, the facility failed to keep the facility in good repair at all times for the well-being of residents.
female bedroom on the left side had torn carpets
the hallway - light is dim, carpet is torn
6 -
oOutlet had no cover and one was broken
oHoles in the walls
oLight doesn ' t work
in the top area in by room 6 - a door had several holes
windows did not have screens
room #6 on the other side of the top floor had holes in the carpet
oHoles in the ceiling tile that were covered in tape
oOne window was missing blinds
oOne window did not have a screen
Males dorms
carpets in the hallway
room with 6 beds had holes in the ceiling tiles and holes in the walls
room with 6 beds had a bunk bed that did not have rails or a ladder
Lower ground floor
box by the smoke exit had cigarette buds and trash in the box.
wing
oThermometer was missing in the freezer
oSheets were holding the AC in the window
oThe third detox room - holes in the ceiling tile
oHoles in the ceiling tile
Basement
room had torn carpet
room hallway had torn carpets
room had stained ceiling tiles
Re-entry area
with 8 beds had torn ceiling tiles
leading to shower room had torn carpet
1st level
room hallway by the women ' s restroom had torn carpet
room had torn carpets
Basement Maintenance Room
The ramp in the maintenance was covered with debri
The findings were discussed during the physical plant tour and exit.
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Plan of Correction
1. Gaudenzia will solicit bids to have the carpeting replaced. Bidding will be open until July 10, 2021. Once bids are obtained, a contractor will be chosen with work to begin within 60 days.
2. A work order was placed by the Program Director on 6/9/21 to have stops placed in all windows without screens which will only allow the window to open 8 inches.
Operations manager will place stops in the windows by 6/30/21.
During the upcoming planned renovations, windows will be replaced.
3. Program Director will complete a purchase request for blinds that are either missing or broken by 6/14/21.
The blinds will be installed by House Managers by 6/21/21.
4. The Operations Manager will replace all missing bedrails and ladders by 6/18/21 with bedrails and ladders that are in the basement of the facility
5. The thermometer for the freezer will be replaced by the Operations Manager by 6/18/21.
6. The Operations Manager and Division Director completed a walk-through of the building on June 4, 2021 to identify the following:
- Light bulbs that are dim / broken
- Ceiling tiles and wall tiles that need replaced
- Outlet covers that are missing or broken
- Holes in the walls and doors.
All items will be purchased and replaced by 7/14/21 by the Operations Manager and House Managers.
The Operations Manager will fix all holes found in walls and doors by 7/30/21.
7. The debris on the ramp in the basement will be removed by the house managers by 6/16/21.
8. The sheet holding the AC in the window has been removed as of 5/21/21.
9. The debris has been removed from the box by the smoke exit as of 5/21/21.
The House Managers Daily Facility Checklist has been updated to include identifying all of the above citations.
The checklist will be reviewed by the Program Director daily and if any item needs replaced or fixed, the PD will complete a purchase order or maintenance request that day.
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the physical plant tour, during the complaint investigation, conducted on May 18, 2021, the facility failed to ensure that counseling session could not be seen or heard.
One large group room had windows that were opened and the blinds drawn and one can see the session during group.
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Plan of Correction
1. The blinds in the large group room will remain closed at all times to ensure the privacy/confidentiality of all clients at all times.
2. All staff have been instructed to keep the blinds closed at all times.
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705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on a physical plant tour, during the complaint investigation, conducted on May 18, 2021, the facility failed to ensure that all bunk beds had ladders and railings on each open side.
female bedroom - one bunk bed did not have a ladder or rail.
1st female room on the left side bunk beds had missing rails
Room 6 - no rail or ladders for the bunk beds,
2nd room # 6 - no rails or ladder on 1 bunk bed
1st room - One bunk bed did not have a secured rail nor a ladder. The one rail was facing the wall.
The findings were reviewed with facility staff during the compliant investigation.
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Plan of Correction
The Operations Manager will replace all missing bedrails and ladders by 6/18/21 with bedrails and ladders that are in the basement of the facility.
This item has been added to the House Managers Daily check list. House managers will identify any railings or ladders that are not properly placed on the beds and immediately place them back on the bed.
The checklist will be reviewed by the Program Director daily and if any item needs replaced or fixed, the PD will complete a purchase order or maintenance request that day.
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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 a physical plant tour, during the complaint investigation, conducted on May 18, 2021, the facility failed to ensure that each shower was slip resistant.
- one shower did not have a slip resistant mat out of the 4 showers
oThere were broken tiles by the showers
oHoles in the ceiling tiles by the showers
shower - 4 showers did not have slip resistant mats and two broken tiles
restroom - shower had didn ' t have a slip mat
room - one shower was missing a slip mat & they also had ceiling tile issues
The findings were reviewed with facility staff during the compliant investigation.
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Plan of Correction
1. The Operations Manager placed an order for non- slip mats on 6/9/21. The mats are expected to be in within a week. The Operations Manager will place the mats in all bathroom areas by 6/18/21.
2. The Operations Manager and Division Director completed a walk-through of the building on June 4, 2021 and identified all of the ceiling tiles and wall tiles that need replaced
All items will be purchased and replaced by 7/14/21. The Operations Manager and House Managers will complete this task.
The House Managers Daily Checklist has been updated to include identifying the above citations.
The checklist will be reviewed by the Program Director daily and if any item needs replaced or fixed, the PD will complete a purchase order or maintenance request that day.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant tour, during the complaint investigation, conducted on May 18, 2021, the facility failed to ensure that each bathroom had an exhaust fan or window.
floor - staff restroom (women ' s) no exhaust fan
Basement - Bathroom had no exhaust fan
The findings were reviewed with facility staff during the compliant investigation.
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Plan of Correction
The Operations Manager will purchase and install an exhaust fan in the women's staff bathroom by July 31, 2021.
The Bathroom in the basement has an exhaust fan that is run by a switch outside the door of the restroom. This is in working order.
The House Managers Daily Checklist has been updated to include identifying the above citation.
The checklist will be reviewed by the Program Director daily and if any item needs replaced or fixed, the PD will complete a purchase order or maintenance request that day.
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