INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 30, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia (Concept 90) 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
Based on a physical plant inspection, the residential facility failed to 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 findings include:
A physical plant inspection was conducted on May 24, 2012 and May 30, 2013. The facility failed to have the interior walls of the building in regulations condition throughout the building. The paint throughout the building was peeling off the walls.
The facility director confirmed this observation and agreed that the paint was peeling from the walls and that repairs were needed.
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Plan of Correction
The Program Director contacted the Gaudenzia Maintenance/Property Manager on 6-3-13 to communicate the defieciency with the interior walls of the building. A painting contractor was dispatched on 6-4-13 to prepare to paint the entire interior of the building. The entirety of the facility will be painted beginning on 6-24-13, with an estimated completion date of 7-5-13. To ensure ongoing compliance with this standard, the Program Director will make monthly maintenance runs throughout the facility with the Maintenance/Property Manager. Any maintenance issues discovered that do not comply with keeping the grounds clean, safe and in good repair will be addressed immediately. |
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
Based on a review of the physical plant, the facility failed to have two unobstructed exits on each floor.
The findings include:
The physical plant was inspected on May 24, 2013 and May 30, 2013. The building failed to have two unobstructed exits on each of the floors.
A review of the basement exits on May 24, 2013 revealed that one of the exit doors was chain locked to avoid exiting to the outside area. The basement stores client possessions and the food pantry. The clients assigned to the kitchen duty must utilize the basement area.
In communication with facility staff, it was reported that the Department of General Services maintains part of the building and chained the exit door closed.
Upon inspection of the basement on May 30, 2013, the exit was unchained and two exits were assessable in the basement area. Two means of egress are required at all times for each floor utilized by staff and clients.
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Plan of Correction
The Program Directer contacted the Maintenance/Property Manager on 5-27-13 regarding the locked gate obstructing the exit in the basement. The Maintenance/Property Manager contacted the Department of General Services maintenance liason about the locked gate obstructing the exit. The gate was unlocked on 5-30-13 leaving full access to the exit. To ensure ongoing compliance with this standard, a daily maintenance run will be made throughout the facility by the House Manager assigned to fire safety/maintenance. Any fire safety/maintenance or obstructed exits will be addressed by the Program Director immediately. |