INITIAL COMMENTS
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This report is a result of an on-site relocation licensure inspection conducted on November 13, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. People With Hope/Short-Term Program 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 facility relocation physical plant inspection conducted on November 13, 2023, the facility failed to maintain the grounds in good repair at all times for the safety and well-being of residents, employees and visitors.
The 3rd floor lounge had floor tile that was loose and raised off of the floor along the wall by the cove base molding which could be a tripping hazard.
The 2nd floor lounge had a cracked floor tile which could be a tripping hazard.
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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 facility relocation physical plant inspection conducted on November 13, 2023, the facility failed to maintain furnishings in a state of good repair.
The 3rd floor lounge couch cushions had material that was cracked and worn.
The 2nd floor lounge chair cushions and arm rest had material that was cracked and worn.
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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 (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 facility relocation physical plant inspection conducted on November 13, 2023, the facility failed to ventilate the bathroom with an operable exhaust fan or window.
The 2nd floor male and female hallway bathrooms contained inoperable bathroom ventilation systems.
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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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705.6 (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 facility relocation physical plant inspection conducted on November 13, 2023, the facility failed to maintain each bathroom in a clean and sanitary manner at all times.
The 3rd floor bathroom across from room # 308 was missing a floor tile near the drain in the center of the floor.
The 3rd floor bathroom across from room # 304 had a black-like substance around the perimeter of both shower stalls between the tile and the shower pan base.
The 2nd floor bathroom shared by room # 202 and room # 204 had a black-like substance throughout the tile grout of the bathtub.
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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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705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a facility relocation physical plant inspection conducted on November 13, 2023, the facility failed to store utensils in a clean enclosed area.
Tongs, whisks, ladles and serving spoons were observed hanging above the dish washing station and not in a clean, enclosed area.
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Plan of Correction
A new container for this purpose was immediately ordered, and is to be in use by 12/22/23.
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.
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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