INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 21st and 22nd, 2019 of Clem-Mar House by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Clem-Mar 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:
|
Plan of Correction
|
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.
|
Observations
Based on a physical plant inspection on February 22, 2018, the facility failed to store all food items off the floor. Cans of sparkling water were observed on the floor.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Our Resident Managers will inspect all food and storage areas on a daily basis to make sure any food or drink items are off the floor. The head Resident Manager will inspect this on a weekly basis as well as preform periodic walks throughout the week. |
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.
|
Observations
Based on a physical plant inspection on February 22, 2018, the facility failed to maintain outside steps exceeding two steps with a well secured handrail. The emergency exit that exits onto Hillside Avenue has three steps and is without a well secured handrail.
The findings were reviewed with facility staff during the licensing inspection process.
|
Plan of Correction
Our maintenance person installed a wooden handrail on the one side of the opening. This will help ensure the safety of anyone entering or exiting through this doorway. |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
|
Observations
Based on a physical plant inspection on February 22, 2018, it was observed that the refrigerator in the medication room, which is used for storage of medication, contained staff food.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Our corporation purchased a separate refrigerator for the staff for any food items to store. The Head Resident Manager will check the medication room refrigerator on a daily basis to make sure no food items are placed inside other than those related to diabetic conditions of clients. |