Observations
The facility failed to maintain each bathroom in a clean and sanitary manner at all times as evidence by the following:
The bathtubs in showers 1 and 4 in the client bathroom were observed to have chipped enamel, along with missing caulk and tiles.
This was discussed with the Facility Director during the investigation.
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Plan of Correction
Recovery Support Professionals (RSPs) shall conduct and document daily rounds in accordance with agency policy. During these rounds, they shall identify and report any observed maintenance or safety concerns. All identified issues shall be promptly reported to the Program Director and Administrative staff.
Program Directors shall conduct and document monthly physical plant inspections to assess the overall condition, safety, and functionality of the facility. Any deficiencies identified during these inspections shall be reported and addressed in accordance with this procedure.
Upon notification of a maintenance concern, administrative staff shall initiate a maintenance work order/ticket in the approved tracking system and shall monitor the status of the request. Follow-ups shall occur no less than weekly until the issue is fully resolved and documented.
Maintenance issues that present an immediate safety risk pose a threat to client health or welfare or significantly impact program operations shall be classified as urgent. Urgent maintenance concerns shall be escalated by the Program Director to the Maintenance Director within 24 hours of identification. Corrective action shall be initiated and documented within 24?48 hours, unless extenuating circumstances are documented.
In the event that repairs cannot be completed within the required timeframe due to internal maintenance scheduling limitations, staffing constraints, or other operational barriers, the use of an approved external vendor shall be considered to ensure timely resolution and ongoing compliance with safety and regulatory standards.
Addendum:
A Maintenance order was promptly placed on 12/10/25. The issues have been partially resolved enamel and caulk on tubes has been repaired. The missing tiles will be completed by 1/23/26.
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