INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on 02/14/2019 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Gaudenzia, 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 exterior grounds were maintained and free from danger to health and safety.
*At the time of inspection, the heating unit on the side of the building leading toward the cold food storage area had an exposed exhaust vent with a temperature of 320 degrees which created a safety hazard.
*There was standing water, leaves and moss accumulated in the lower stairwell outside the emergency exit from the basement located on the east side of the facility.
*There was black mold on the ceiling tiles in the basement near the entrance to the laundry room.
* Rooms #1, #3, #4, #5 and #6 had heater vents that were flaking paint, rusty and created cut hazards around the vent area.
*At the bottom of the stairs in the freezer area there was a concrete hump that created a trip hazard.
* A fluorescent light fixture in the freezer area was not properly secured to the ceiling.
* The emergency exit outside of the 1st floor kitchen to the street had snow and ice on the walkway.
* The emergency exit outside of the 1st floor stairwell to the south side of the building had a moss-covered mat that created a slip hazard.
* Rm #13 had wires hanging out of the wall and a broken plastic cover that was sharp creating a hazard.
*The fire escape leading from the men ' s door area needs to be painted. It was rusted, and the paint was peeling.
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Plan of Correction
Director has followed up with the Division Director that oversees the program that utilizes the heating unit. Maintenance Department has been informed and contractors have been out to asses and provide a quote. A final decision of a contractor will be made by 5/13/2019, after that the work to address the issue will begin. The Maintenance Department has added the heating unit on their monthly checklist so that that it can be assessed monthly to assure that no further issues have occurred. Once Maintenance completes the monthly checklist, it will be submitted to the Director and Maintenance Department fo follow-up as needed.
On 4/15/2019, all standing water, leaves, moss that was accumulated in the lower stairwell has been removed. All outside stairways have been added to the exterior checklist to ensure that they are cleaned from any debris daily. The completed checklist is then given to Director or Designee to follow-up to make that there is no debris present. The laundry room has been cleaned thoroughly and all possible mold was addressed on 4/28/2019.
Operation Staff walk through the facility daily and note any issues by submitting a maintenance work order form. 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. Heater vents in rooms #1, #3, #4, and #5 were all replaced on 3/12/2019. The fluorescent light fixture in the outside freezer area has been repaired. The ceiling was replaced and the light fixture has been secured. This area has been added to the checklist to be assessed weekly and any issues will be reported and documented. The facility has a contractor that will take care of all snow and ice removal including the parking lot, all walk ways. This will be monitored by the Director or Designee to assure that the ice and snow are removed as needed. The wires and the broken plastic cover were that were exposed in room #13 have been removed and the wall has been repaired. The fire escape in the men dorm has been sanded down and painted. This will be inspected monthly while Director and maintenance worker tour the facility to ensure that the paint is not peeling from the walls. |
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 141 degrees.
*First-floor east bathroom water temperature was 141 degrees.
*Women's bathroom #2, sink #3 had a water temperature of 138 degrees
*Sink #1 had no hot water.
*Women's bathroom #1 Sink #1 had water temperature of 136.5 degrees.
*Men ' s Bathroom #3 had a water temperature of 138.2 degrees.
*Men ' s Bathroom #2 had a water temperature of 138.8 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 keep temperature logs until June 30, 2019 (3 months) to assure that the temperature continues to read less than 120 degrees. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
The facility failed to ensure privacy in each bathroom.
The women's bathroom #1, had windows that opened on to an interior stairwell to another area of the facility. Even though the blinds were down there was visual access to the bathroom from this stairwell.
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Plan of Correction
Director had Maintenance install a frost on both windows in bathroom #1 to insure privacy in the bathroom. The windows are checked weekly by the House Managers conducting facility tours. The checklist is placed in the Director's mailbox once completed. The Director reviews the checklist to make sure there are no areas that need follow-up attention. The frost were installed on the windows on 4/15/2019. |
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.
*In the female bathroom in the basement there were sharp surfaces on the heater cover which created a safety hazard.
*In the women's bathroom #2 there was also mold observed around the entrance door frame. The paint in this bathroom was also bubbling and peeling. It appeared that there was moisture behind the walls.
*In the women's bathroom #1, the exhaust vent was dirty in the 1st shower stall. Toilet stalls #1 and 2 had jagged metal remnants from the toilet paper holders which were removed
*Men ' s Bathroom #2. The center frame between the toilet stalls had a sharp edge on the frame that could be a cut hazard.
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Plan of Correction
Gaudenzia House West Chester will be completing a major upgrade in all bathrooms. We are completely gutting and renovating the bathrooms on the men's and women's dorms including the medical bathroom and the bathroom in the basement. This complete overhaul will satisfy all deficiencies noted previously. The first bathroom to be shut down for complete renovation is in the men's dorm. The renovation began on 4/22/2019. We will then proceed to renovate the other two bathrooms in the men's dorm and continue moving to the others. The bathroom renovations will continue until all bathrooms have been fully renovated. All work is expected to be completed by July 1, 2019. |
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 a well-secured handrail on an interior stairway.
The stair well, next to the women ' s dorm entrance, had a loose handrail leading from the 1st to 2nd floors.
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Plan of Correction
Maintenance has secured the handrail in the interior stairway on 4/15/2019. All handrails have been added to the weekly maintenance checklist that is completed by House managers during the facility tour, this will assure that all handrails are assessed weekly. In the event that there are any issues they are addressed immediately and documented on the checklist by maintenance. The checklist is completed weekly and placed in the Director's mailbox to be reviewed to make sure that no follow-up is needed. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
The facility failed to ensure that stairs were lighted at all times.
The entrance into the walk-in freezers was not properly illuminated.
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Plan of Correction
Director informed the Maintenance worker to install a sensor light in the entrance leading to the freezer box. The light was installed on February 19, 2019. Director has instructed Kitchen Supervisor to add the freezer box to the checklist of areas that need to be checked for any issues daily. There is now a running log to note any issues identified. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to ensure the confidentiality of client identity.
The front door to the facility was not locked when DDAP staff arrived; no one was stationed at the entrance to ensure that visitors to the facility were checked in, which allowed DDAP staff to enter and walk through the facility observing residents in the facility participating in group counseling and various activities.
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Plan of Correction
On 4/18/2019, Director implemented a system where there is a staff person sitting in the reception area. This will assure that client identity is kept confidential and no visitor will be allowed to leave the reception area unless they are being escorted by a staff person. The reception staff will also make sure that all visitors sign the visitors binder and are a given a visitors Tag. |
709.53(a)(12) LICENSURE Work as treatment
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
The facility failed to provide verification that work done by clients is an integral part of the treatment and rehabilitation plan.
Client #1 admitted 11/27/18 and still active at the time of the review. Treatment plans 12/14/18 and 1/22/19 did not reflect "work therapy" in the treatment goals. In addition, there were no progress notes indicating that work being done was part of "work therapy".
Client #2 admitted 11/28/18 and still active at the time of the review. Treatment plans dated 11/29/18 and 12/15/18 did not reflect "work therapy" in the treatment goals. In addition, there were no progress notes indicating that work being done was part of "work therapy".
Client #4 who was observed painting on the 2nd floor men's dorm, was admitted 01/03/19 and still active at the time of the review. His treatment plan dated 01/06/19 did not reflect "work therapy" in the treatment goals. In addition, there were no progress notes indicating that work being done was part of "work therapy".
Client #5, who was observed painting on the 2nd floor men's dorm, was admitted 01/18/19 and still active at the time of the review. His treatment plan dated 02/11/19 did not reflect "work therapy" in the treatment goals. In addition, there were no progress notes indicating that work being done was part of "work therapy".
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Plan of Correction
Director and Program Supervisor provided several trainings (5/6/2019, 5/7/2017 and 5/9/2019) on how to properly complete treatment plans that will include all activities and progression or lack of progression of the client. Within the training we discussed the proper way to include the client's progress and involvement in the program and where and how to document any work therapy that the client maybe involved in. All Counselors were asked to bring a copy of current treatment plans, then after the training they were asked to generate new treatment plans to assure that they understood the concept. During each Counselor's supervision, the Supervisor along with the Counselor will review one to two charts to ensure that all clinical documentation is present and completed correctly. This will also allow for the supervisor to audit the chart and correct any issues that may exist and answer any questions that the Counselor may have. Director will also perform bi-weekly audits on random client charts to assure that all clinical documentation is completed correctly in the client chart. |