INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on November 13, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Gaudenzia-New Destiny was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
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.
|
Observations
Based on a physical plant inspection conducted on November 13, 2024, the facility failed to be in good repair at all times for the safety and well-being of residents, employees, and visitors.
The bathroom for room # 114 was observed to have two ceiling tiles that were discolored and bowed, no longer flush with the other ceiling tiles.
The third-floor hall bathroom has a cracked toilet seat in the second stall.
The bathroom for room # 112 and room # 113 has a chair with a tear in the leather-like material.
|
Plan of Correction
1. Upon discovering the discolored and bowed ceiling tiles, the Program Director entered a work order for the Maintenance department. The work order was completed and confirmed.
The program director will monitor ongoing compliance through monthly plant audits, and extra ceiling tiles will be kept on-site for replacement if needed.
Completed 11/20/2024
2. Upon discovering a cracked toilet, the Program Director entered a work order for the maintenance department. The work order has been completed and confirmed.
Ongoing compliance will be monitored by implementing a bathroom maintenance sheet, which staff will complete daily and hand to Administrative Assistance for review and to enter a work order for any future maintenance.
Completed 11/20/2024
3. A chair was discovered in the bathroom of rooms 112 and 113. It was immediately removed and thrown in a garbage dumpster, and a new chair was replaced.
Ongoing compliance will be monitored by a daily bathroom maintenance sheet to be completed by staff and reported to Administrative Assistance to enter a work order for future maintenance.
Completed 11/13/2024
|
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.
|
Observations
Based on a physical plant inspection conducted on November 13, 2024, the facility failed to maintain each bathroom in a functional manner at all times.
The bathroom situated between room # 105 and room # 107B was observed to have a clogged sink. There was standing water in the sink that was not going down the drain.
|
Plan of Correction
Upon discovering a clogged sink between rooms 105 and 107B, the program director plunged the sink, and the water drained. A work order was entered for maintenance because, after clearing and running water, the sink continued to remain clogged. The work order was completed, and the sink was cleared of blockage.
Ongoing compliance will be monitored by implementing a bathroom maintenance sheet, which staff will complete daily and hand to Administrative Assistance for review and to enter a work order for any future maintenance.
Completed 11/14/2024
|
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
|
Observations
Based on a physical plant inspection conducted on November 13, 2024, the facility failed to maintain protective caps over each electrical outlet.
The suite for room # 114 had three electrical outlets that were each missing one child safety plug.
|
Plan of Correction
Upon discovering electrical outlets missing in room 114, the Program Director immediately installed new covers on them.
Staff will check the ongoing monitoring of electrical outlets daily during house runs as listed on the checklist; Administrative Assistance will review daily, ensuring any replacements are made immediately upon discovering outlet covers and maintaining a supply of additional outlet covers at all times.
Completed 11/13/2024
|