INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on October 2, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Clem-Mar House Inc. (Edwardsville) 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 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection, the facility failed to have lids on the trash containers located in the dining area.
The findings include:
Four trash containers were inspected in the common room of the facility on October 2, 2012. This room is also used as the dining area for this residential program. The inspection was completed at 10:30 A.M. This time period was after breakfast and before lunch. The trash containers had trash in the containers and failed to have covers on them.
This finding was confirmed by the maintenance employee during the physical plant inspection.
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Plan of Correction
The lids were replaced on the bins immediately after the inspection on 10/2/12. To prevent recurrence, each Resident Manager on duty will be inspecting disposal bins 2x daily. |
705.7 (a) LICENSURE Food service.
705.7. Food service.
(a) A residential facility shall provide meals to residents through onsite food preparation areas, a central food preparation area or contractual arrangements with vendors or caterers.
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Observations
Based on observation during the physical plant inspection, the facility had outdated food items stored in the pantry aside of the kitchen area.
The findings include:
The physical plant inspection was conducted on October 2, 2012 at approximately 10:30 A.M. The kitchen pantry was checked for outdated food.
The following items were outdated:
1. Ken's Blue Cheese Dressing expired on August 23, 2012
2. BBQ Sauce expired on January 21, 2012
3. A package of noodles had an expiration date on May 2, 2010
4. Pancake mix October 2011
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Plan of Correction
All expired food items were disposed of on the date of the surveyor's visit- 10/2/12. On 10/8/12, the senior resident manager created an inventory log sheet that details each food item that is brought into the facility and its' expiration date to prevent recurrence. In addition, each resident manager is checking all food storage areas on a 3x daily (each shift) basis to ensure that all expired items are discarded prior to expiration/use by date. This will be overseen on a daily basis by the senior resident manager. |
705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on an inspection of the physical plant the facility failed to failed to keep the freezer temperature at 0 degrees Fahrenheit or lower for storage of food.
The findings include:
During a physical plant inspection on October 2, 2012 the freezer the clients use to store personal food items needs to be maintained at regulation temperature of 0 degrees or lower. This freezer is located in the dining area and had a temperature reading of 20 degrees.
This finding was confirmed by the maintenance employee conducting the physical plant inspection on October 2, 2012.
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Plan of Correction
The food was removed from the freezer with the higher temperatures on 10/2/12 after the survey was completed. At that time, the freezer was defrosted and has been holding its' temperature steadily. To prevent recurrence, the senior resident manager held a training meeting with the RM staff on 10/10/12 to retrain on correct temperature understanding by residential team, and a policy has been put in place that any temperature over 0* F will be verified and work order will be put in for freezer repair/defrost during that shift to ensure repair within 24 hours (After all food has been moved to freezer with appropriate temperatures.)
The senior resident manager will oversee the temperature logs on a daily basis. |