INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on December 4-5, 2019 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site complaint investigation, Gaudenaia Inc. West Chester 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
The facility failed to ensure that the grounds were maintained and free from danger to health and safety.
In the basement:
junction box/light switch in the laundry room was not secured to the wall.
exit stairwell from the laundry room was covered in leaves which creates a potential slip, fall hazard..
the ceiling of laundry room there was mildew.
lint accumulation and potentially combustible materials behind the dryers.
1st floor women ' s area:
#6: the closet had heavy paint flaking and water damage on the ceiling.
#5: there was water damage and mildew on the ceiling tiles in the closest. There were nails sticking out of a shelf in the closest which is a safety hazard. The shelf in the closet was damaged and not properly secured.
#4 missing and broken tiles on floor
2nd floor men ' s area:
Room: Ceiling in closet was missing tiles and insulation was hanging from the ceiling; the florescent ceiling lights did not have a cover.
#2: Hole in the floor toward the back of the room, under the dresser.
#3: Tiles were loose and coming up from the floor, there was a hole in the wall.
near Room #3: potentially live electrical wires were exposed on the left side of the wall; broken glass in the bottom landing. There was also peeling paint in the stairwell.
emergency pull station across from room #8 is not secured to the wall.
#11: HVAC duct cover damaged.
#10: Paper was placed into the florescent light cover.
#5: outlet and outlet cover plate was not secure. An intercom/call button was not secured to the wall and electric wires were the only mechanism holding the fixture. In the closet electrical wires were hanging from the ceiling and paint was peeling.
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Plan of Correction
On 12/7/2019, all leaves that was accumulated in the lower stairwell were removed. All outside stairways have been added to the exterior checklist to ensure that they are cleaned from any debris on a daily basis. The completed checklist is then given to the Director or Designee and the House Manager Supervisor to follow-up to make sure that there is no debris present. The laundry room has been cleaned thoroughly and all possible accumulation of lint, combustible material and mildew were addressed on 12/7/2019.
All dorms (men and women) are being professionally painted and all holes on the wall are being patched, nails have been removed from the walls, broken tiles were repaired, and ceiling tiles and light covers have been replaced. All exposed wires have been removed as they are un-operable, the pull station has been secured to the wall. This is an active project and is scheduled to be completed on January 23, 2020.
Operation Staff are walking through the facility daily and noting any issues by submitting a maintenance work order form to the Director and House Manager Supervisor. At the end of the week a weekly report is generated and submitted to Director that shows any issues that were identified, the date the maintenance order form was submitted and the date the issue was addressed. In addition, the Maintenance Worker along with the Director tour the facility at least once a month to ensure that any damage ceiling tiles, any signs of dirt or stains are addressed immediately. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The facility failed to ensure that each bathroom had hot water and that water temperature was below 120 degrees.
The bathroom in the women ' s residential wing had a water temperature of 132.2 degrees.
The bathroom in the basement had a water temperature of 134.2 degrees.
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Plan of Correction
Director and Maintenance worker adjusted the temperature on the boilers to reduce the temperature reading in all the sinks. The temperature to all sinks including the bathrooms have been checked daily and have been reading below 120 degrees to date. Director has been keeping track of all sinks including the bathrooms temperature and logging them. Director will continue to have the temperature logged and recorded in the binder to assure that the temperature continues to read less than 120 degrees. The binder will be reviewed weekly by Director or Designee to assure continued compliance. |
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
The facility failed to ensure that bathrooms were maintained in a functional, clean and sanitary manner.
Women's bathroom #2 had a clogged sink with standing water. There was what appears to be mold/mildew on the evacuation sign in this restroom.
Basement Bathroom The 1st toilet was out of order.
2nd toilet stall door was too narrow for the opening and could not be locked.
The heater cover in the back of the bathroom was heavily rusted and had a sharp lower edge which is a safety hazard.
The paper towel dispenser was broken and hanging open.
The sink cabinet was missing drawers and heavily damaged.
Men ' s Bathroom #2. The center door frame between the stalls had a sharp edge on the frame that is a safety hazard.
An electrical plate on the right- hand side of the wall, had sharp protrusions that created a safety hazard.
Men ' s Bathroom near Davis room: soap dispensers were not mounted on the wall.
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Plan of Correction
The bathroom in question women's bathroom #2 is currently being renovated. The entire bathroom has been gutted out and is expected to be remodeled up and running by February 1, 2020. All issues noted will be addressed.
Director ensured that new soap dispensers were mounted in men's bathroom near Davis dorm.The electrical plate on the side of the wall has been enclosed and secured. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
The facility failed to maintain each interior stairway with a well-secured handrail.
The emergency exit stairwell near Room #3 had a handrail that was not properly secured to the wall.
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Plan of Correction
The handrail was secured by the Maintenance Worker on December 5, 2019. As the Operation Staff conduct their facility tours they will be able to observe any issues with the handrails as they have been added to the checklist. If there is an issue the staff will immediately complete a maintenance order and forward to the House Manager Supervisor as well as the Director and Maintenance Worker. This is on-going. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
The facility failed to protect the confidentiality of client records
A staff member was working at a table in the entry hall with incident reports and other papers containing client identifying information; this information was unsecured and client information was observed on these documents by DDAP staff.
This information was disclosed to the facility staff in order to protect confidentiality.
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Plan of Correction
Director has ensure that any staff that is monitoring the reception area does not have any documents with client information. This was implementing immediately upon Director being notified on December 4, 2019. The Director monitors the reception area remotely via camera and walks through several times per day to assure that client identifying information is not anywhere in the reception area. This new system is on-going. |