INITIAL COMMENTS
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This report is a result of an onsite complaint investigation conducted on May 12, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the investigation, Gratitude House 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
A physical plant inspection was conducted on May 12, 2017. Based on this inspection, the facility failed to keep the exterior of the building free from hazards as two windows on the first floor had torn screens, all the second and third floor bedroom windows had screens missing, and the window pane in Bedroom # 5 was cracked. The building roof had leaks in the gym and Bedroom # 10.
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Plan of Correction
All new fold out screens have been purchased and installation in bedroom windows was completed. The window pane in bedroom #5 was replaced on May 29, 2017. We have a signed purchased order with Blair Roofing to replace the roof. Work is scheduled to begin June 5, 2017. Once the new roof is installed, we will begin replacement of dry wall and ceiling tiles that were affected by previous roof leaks. |
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
A physical plant inspection was conducted on May 12, 2017. Based on this inspection, the facility failed to maintain the furnishings in the living rooms and lounges in good repair as the chairs were torn, dirty, and missing cushions.
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Plan of Correction
All new furniture was purchased and set up on June 1, 2017 in the upstairs TV lounge. All old furniture was removed from the facility on June 1, 2017. |
705.5 (h) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(h) Each bedroom shall be ventilated by operable windows or have mechanical ventilation.
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Observations
A physical plant inspection was conducted on May 12, 2017. Based on this inspection, the facility failed to ensure that the windows in the bedrooms were operable as the windows were kept open by hygiene product bottles.
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Plan of Correction
On May 23, 2017 we received new fold out screens for the bedrooms that did not have screens. This will ensure proper ventilation, as well as, safety for all residents. All screens will be installed by June 9, 2017. We are presently awaiting an estimate on replacing all windows at Gratitude. |
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
A physical plant inspection was conducted on May 12, 2017. Based on this inspection, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner as the second-floor bathroom had water leaking on the floor and had ceiling tiles that were stained from a leak in the roof. In addition, the floors of the bathrooms had black mold around the showers and tubs.
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Plan of Correction
All showers and bathtubs were cleaned and the caulking was replaced around the tubs/showers on 5/15/17. Degols Flooring will be submitting bids for replacement of the flooring in all bathrooms. Upon completion of the roof, we will begin the remodeling of each bathroom. The remodeling of all bathrooms will be completed by 9/29/17. Staff will ensure that proper cleaning/sanitation is maintained. |
705.7 (b) (2) 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:
(2) Clean and disinfect food preparation areas and appliances following each prepared meal.
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Observations
A physical plant inspection was conducted on May 12, 2017. Based on this inspection, the facility failed to clean and disinfect the food preparation areas and appliances following each prepared meal as the area and appliances were not washed and had rodent dropping covering them.
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Plan of Correction
A deep clean of the kitchen area was conducted on 6/1/17. Staff ensured all counter tops, stove top, preparation area were all disinfected and deep cleaned. During food preparation and after each meal, staff will ensure that all areas are cleaned up appropriately and cleaned/disinfected prior to and following each meal. Staff will complete a clean-up check list to be conducted after every meal to ensure proper cleanup/sanitation of the kitchen area. Staff and Residents will be educated on proper food management, clean and disinfecting food preparation areas, and maintaining clean appliances as part of their life skill's program. Ehrlich will continue to provide monthly visits to the facility to address the rodent issue. We will ensure that all traps/bait stations are in secure places away from any food preparation or eating areas. Ehrlich has been working with the Director of Maintenance on being aggressive with sealing all holes, they increased the number of traps, and will conduct visits twice a month or more as needed, to ensure the rodent issue improves. |
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
A physical plant inspection was conducted on May 12, 2017. Based on this inspection, the facility failed to clean all eating, drinking, and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area as there were rodent stick pads and dropping all around the drinking area. In addition, the cooking utensils were kept in a container that did not have a lid and were covered in rodent droppings. Per client interviews, the cleaning chemicals for the dishwasher were not refilled for over two weeks. At the time of the inspection, full cleaning chemical containers were found in the kitchen.
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Plan of Correction
Cooking appliances and utensils will be cleaned immediately following each meal. Utensils will be kept in a plastic bin with a lid to ensure there is no contamination. Pots/Pans/Dishes will be kept in a metal cabinet, for proper sanitation. Staff will ensure that the drink area is cleaned immediately following each meal. Sugar, creamer etc will be kept in plastic bins with lids. Maintenance will continue to ensure that they cleaning chemicals are available for the dishwashing machine. Staff will check the machine daily to ensure cleaning chemicals are full. A deep clean of the food dry storage was conducted on 6/1/17. Cleaning/dusting of this room will be a daily chore. Staff will check daily with other chores to ensure it is being completed. |
705.7 (b) (4) 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:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
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Observations
A physical plant inspection was conducted on May 12, 2017. Based on this inspection, the facility failed to ensure that store areas for food were free of food particles, dust, and dirt as there were rodent droppings on the shelves where the food was kept.
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Plan of Correction
Staff will ensure the kitchen area is cleaned appropriately after each meal. Once a week, a deep clean of the kitchen will be conducted as well. The lead housekeeper from Pyramid will conduct an educational piece with staff regarding cleaning procedures by June 16, 2017. Ehrlich will continue to provide monthly services to the facility. We will continue to utilize bait traps to assist with the issue. Staff will ensure that proper cleaning and disinfecting occurs to help eliminate ongoing problems. |
705.7 (b) (7) 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:
(7) Prohibit pets in the food preparation area.
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Observations
A physical plant inspection was conducted on May 12, 2017. Based on this inspection, the facility failed to prohibit pets from the food preparation area. The facility's dog was wandering throughout the facility unattended.
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Plan of Correction
Staff will ensure that no animals are in the kitchen/dining area at all times. Staff will ensure that protocol for sanitary cleanliness are followed at all times. |
705.8 (1) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(1) Shall have a heating and cooling ventilation system that is adequate to maintain an indoor temperature of at least 65F in the winter. When indoor temperatures exceed 90F, mechanical ventilation such as fans or air conditioning shall be used.
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Observations
A physical plant inspection was conducted on May 12, 2017. Based on this inspection, thefacility failed to correctly ventilate the cooling system as an air conditioning unit located inthe lounge area was placed on a chair instead of in a window to ensure proper ventilation.
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Plan of Correction
Maintenance checked all air conditioners on May 13, 2017. All air conditioners are securely installed in all rooms. |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
A physical plant inspection was conducted on May 12, 2017. Based on this inspection, the facility failed to be free of rodent infestation as there were rodent droppings throughout the facility (in the kitchen, bedrooms, hallways, and in the gym).
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Plan of Correction
Ehrlich will continue to provide services to assist with the rodent infestation. Staff will ensure that the kitchen is being properly cleaned and disinfected after every meal. Staff will work to ensure that all food is kept in the kitchen/dining area. Garbage cans continue to be emptied once a day, except for the kitchen which will occur after every meal. |
705.9 (2) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(2) Require that pets housed in the residential facility are cared for in a safe and sanitary manner.
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Observations
A physical plant inspection was conducted on May 12, 2017. The facility failed to provide documentation of shot records or veterinary bills to indicate that the facility's dog was cared for in a safe and sanitary manner.
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Plan of Correction
Veterinary records were emailed to Mr. Burke on June 1, 2017. |
705.10 (b) (3) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(3) Repair inoperable smoke detectors or fire alarms within 48 hours of the time the detector or alarm is found to be inoperative.
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Observations
A physical plant inspection was conducted on May 12, 2017. Based on this inspection, the facility failed to repair inoperable smoke detectors as Bedroom #8 had a smoke detector hanging from the ceiling with the wires exposed.
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Plan of Correction
On May 13, 2017 Pyramid Maintenance checked all smoke detectors in the facility. The smoke detector in Room #8 was relocated in the room on May 13, 2017. The maintenance department will conduct regular checks and maintenance on all smoke detectors throughout the building. |