INITIAL COMMENTS
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This report is a result of an onsite relocation and capacity decrease licensure inspection conducted on November 13, 2023, by staff from the Bureau of Program Licensure. Based on the findings of the onsite inspection, Gaudenzia Together House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this re-location inspection and a plan of correction is required.
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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 November 13, 2023 during a relocation inspection, the facility failed to maintain each bathroom in a clean and sanitary manner.
Bedroom 603 has two windows without window coverings.
Bedroom 604 has a chipped windowsill with pieces of wood material missing.
This was discussed with facility staff at the time of the relocation inspection.
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Plan of Correction
The Maintenance department was immediately notified, and repairs are already in progress, with an anticipated completion date of 1/12/24.
In order to ensure that these and other physical plant issues to not go unaddressed, the Recovery Support Professional (RSP) staff will monitor all areas of the physical plant on a daily basis and complete a documented walkthrough of the facility at least weekly. Any issues noted will be reported to the Program Director and forwarded to the Maintenance department via a ticket entered into the Megamation maintenance request software. The Program Director will follow up on any outstanding requests and notify the Deputy Director.
The physical plant will also be inspected at least quarterly during Gaudenzia CQI reviews of the program. Any issues noted will be documented in a report and brought to the immediate attention of the Program Director to be addressed as noted above.
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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection conducted on November 13, 2023 during a relocation inspection, the facility failed to maintain furnishings in a state of good repair.
The furniture in the client lounge was observed to have worn and cracked cushions.
This was discussed with staff at the time of the relocation inspection.
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Plan of Correction
New furniture has been ordered for the program to replace all items in disrepair, with an expected delivery date of no later than 1/31/24.
In order to ensure that these and other physical plant issues to not go unaddressed, the Recovery Support Professional (RSP) staff will monitor all areas of the physical plant on a daily basis, and complete a documented walkthrough of the facility at least weekly. Any issues noted will be reported to Program Director and forwarded to the Maintenance department and Operations Manager via a ticket entered into the Megamation maintenance request software. The Program Director will follow up on any outstanding requests, and notify the Deputy Director.
The physical plant will also be inspected at least quarterly during Gaudenzia CQI reviews of the program. Any issues noted will be documented in a report, and brought to the immediate attention of the Program Director to be addressed as noted above.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on November 13, 2023 during a relocation inspection, the facility failed to maintain each bathroom in a clean and sanitary manner.
The shower room across from room 608 was observed to have a black mold-like substance around the shower pan in both shower stalls.
The shower room across from room 604 was observed to have a black mold-like substance on the tile grout and along the shower pan in both shower stalls.
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Plan of Correction
Work orders entered.
The Maintenance department was immediately notified, and repairs are already in progress, with an anticipated completion date of 1/12/24.
In order to ensure that these and other physical plant issues to not go unaddressed, the Recovery Support Professional (RSP) staff will monitor all areas of the physical plant on a daily basis, and complete a documented walkthrough of the facility at least weekly. Any issues noted will be reported to Program Director and forwarded to the Maintenance department via a ticket entered into the Megamation maintenance request software. The Program Director will follow up on any outstanding requests, and notify the Deputy Director.
The physical plant will also be inspected at least quarterly during Gaudenzia CQI reviews of the program. Any issues noted will be documented in a report, and brought to the immediate attention of the Program Director to be addressed as noted above.
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