INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from September 11-12, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia - New Destiny, 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 upon the physical plant inspection, the facility failed to keep the grounds of the facility safe and in good repair at all times for the safety and well-being of residents, employees and visitors.
The findings include:
The access road and parking areas that were utilized by the facility were inspected on September 12, 2012, at approximately 8:10 AM.
The facility is located off of a main highway and is accessed via a paved road that proceeds through the grounds of a former hospital. The facility's main access road begins toward the rear of the hospital, proceeds around a right hand turn and up an incline to the facility. The road then continues around the right side of the facility and down to and through a lower parking area. The access road then ends where it reconnects with the hospital's road that leads to and from the highway.
The lower portion of the access road and lower parking area contained a minimum of 4 potholes that measured over 36 inches wide and 1 pothole that was smaller. The smallest of the potholes was located toward the bottom of the access road as it leads toward the parking area. The last pothole, which measured over 36 inches wide, was located at the end of the access road, where it reconnects to the hospital road. The potholes presented a hazard to both people and vehicles.
The findings were confirmed by the Facility Director and the Property Manager. The Property Manager had initiated repairs by the time the inspection was concluded.
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Plan of Correction
The grounds of the facility must be safe and in good repair at all times for the safety and well-being of residents, employees and visitors. On 9/12/2012 four large and one small pothole were patched by utlizing a shredded asphalt compound to fill the holes. Work was completed by end of workday on 9/12/2012. It is the responsibiility of the program director to report to the Division Director and Facilities Maintenance Manager any problems relating to safety of the grounds and building so that repairs can take place. Issues related to safety will also be reported monthly to the agency-wide Safety Committee. This report is completed by the Case Manager with final review by the Program Director. This correction is in effect as of October 1, 2012. |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that all food items were stored off the floor.
The findings include:
The physical plant inspection was conducted on September 12, 2012, from approximately 1:45 PM to 2:30 PM.
The facility maintained two food pantries that are situated side by side. While inspecting the left side pantry, the Licensing Specialist observed that two cases of juice were stored on the floor, underneath a shelving unit.
The findings were confirmed by the Facility Director during the physical plant inspection. The Facility Director then had the boxes of juice placed on a shelf inside the pantry.
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Plan of Correction
All food items must be stored at least 6 inches off of the floor. On the date of the inspection two boxes of food were removed from the floor and placed on the shelves. On 9/13/2012, staff and clients were informed that all food must be stored off of the floor and staff doing house runs must insure that food remains off of the floor. |