QA Investigation Results

Pennsylvania Department of Health
AVENUES RECOVERY MEDICAL CENTER AT VALLEY FORGE, LLC
Health Inspection Results
AVENUES RECOVERY MEDICAL CENTER AT VALLEY FORGE, LLC
Health Inspection Results For:


There are  21 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:

This report is the result of a full State Licensure survey conducted on May 27, 2021, and completed on August 3, 2021, at Avenues Recovery Medical Center At Valley Forge, Llc. It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 Pa Code, Part IV, Subparts A and B, November 1987, as amended June 1998.



Plan of Correction:




111.14 (3) LICENSURE
DRY STORAGE

Name - Component - 00
111.14
(3) The food products must be protected from contamination by condensation, leakage, mopping, insects, rodents, or vermin.

Observations:

Based on observation, review of facility policy and interview with staff (EMP), it was determined the facility failed to store food and dry goods in a manner that afforded protection from contamination.

Findings include:

A review of facility policy "Storage" not dated revealed "Purpose: All food, chemicals, and supplies should be stored in a manner that ensures safety and quality of products and minimizes risk of damage or injury to individuals. Instructions: Employees who receive and store food maintain storage areas, including dry, refrigerated, and freezer storage, by following these steps: ...Storage upon Receiving: ...6. Make sure all goods are dated with receiving date and/or use by or package date. 7. Store food in original container if the container is clean, dry, and intact. After a food package is opened, remaining product can be stored in clean, food grade, labeled, and airtight containers... 8. Monitor length of storage of foods. Most prepared foods should be used or discarded within 7 days."

An observational tour conducted on May 27, 2021, with EMP1, EMP2, and EMP3 at 1:15 PM to 1:52 PM of the facility dietary department revealed the following:

An observation of dry goods stored on large wire racks revealed no splash guards (protective barriers) on the bottom shelves of the large wire racks. Further observation revealed cardboard boxes containing packages of crackers and potato chips stored on the bottom shelf without a splash guard barrier.

An observation of a "zip-lock" bag containing dry cereal revealed it was labeled with an open date of April 25, 2021. Further observation revealed no beyond use date was noted on the zip-lock bag.

An observation of an open package of long thin pasta revealed it was wrapped in clear plastic wrap. Further observation revealed there was no open date and beyond use date on the package.

An observation of an open package of dry buttermilk revealed it was labeled with an open date of April 21, 2021. Further observation revealed no beyond use date was noted on the package.

An observation of an open bag of pasta revealed the bag was closed by a knot at the top of the bag. Further observation revealed there was no open date and beyond use date on the bag.

An observation of an open bag of rice revealed the bag was closed by a knot at the top of the bag. Further observation revealed there was no open date and beyond use date on the bag.

An observation of open containers of dried spices revealed there was no open dates and beyond use dates on the spice containers.

An interview conducted on May 27, 2021, with EMP1, EMP2, and EMP3 at 1:30 PM confirmed the dry goods were not stored in a manner that ensured food safety for those items. Further interview confirmed the bags and packages of dry goods and spices were not stored in clean, food grade, labeled, and airtight containers and labeled with open and beyond use dates according to the facility's policy.

Cross Reference:
111.15: Storage of Perishable Food






Plan of Correction:

The Dietary Supervisor conducted an audit and ensured that all items are labeled, dated and stored in appropriate containers according to the policy.

The Food Storage: Dry Goods Policy was updated, reviewed and dated. All dietary employees will be re-educated on the policy by the Dietary Supervisor and it will be documented on the inservice record sign in sheet by November 21, 2022.

The Dietary Supervisor or Designee will audit the food storage room 3xs a week to ensure appropriate open and beyond use dates, labeled and appropriate storage containers are in use and remediate as necessary.

The Executive Director and/or Designee will report the results of the audits to the Quality Assurance Performance Improvement Committee Monthly until 100% compliance is achieved for three months.

The Dietary Supervisor will order splash guard for the bottom of each wire rack by 11/14/2022. The Dietary Supervisor will audit the wire rack 3xs a week to ensure the splash guard is in place.

The Dietary Supervisor will educate all dietary employees that the splash guard must be in place at all times and it will be documented on an inservice record sign in sheet by November 21, 2022.

The Dietary Supervisor or Designee will audit the wire rack 3xs a week to ensure the splash guard is in place and remediate if needed.

The Executive Director and/or Designee will report the results of the audits to the Quality Assurance Performance Improvement Committee Monthly until 100% compliance is achieved for three months.



111.15 LICENSURE
STORAGE OF PERISHABLE FOOD

Name - Component - 00
111.15 Storage of perishable foods.

Perishable foods shall be refrigerated at the appropriate temperature and in an orderly and sanitary manner as provided in regulations of the Department of Environmental Resources, set forth in 7 Pa. Code 78.21-78.24, 78.31 and 78.32 (Reserved). Foods being displayed or transported shall be protected from contamination and held at proper temperatures in clean containers, cabinets or serving carts.

Observations:
Based on observation, review of facility policy and interview with staff (EMP), it was determined the facility failed to store perishable food at proper temperatures and in a manner that afforded protection from contamination.

Findings include:

A review of facility policy "Storage" not dated revealed "Purpose: All food, chemicals, and supplies should be stored in a manner that ensures safety and quality of products and minimizes risk of damage or injury to individuals. Instructions: Employees who receive and store food maintain storage areas, including dry, refrigerated, and freezer storage, by following these steps: ...Storage upon Receiving: ...6. Make sure all goods are dated with receiving date and/or use by or package date. 7. Store food in original container if the container is clean, dry, and intact. After a food package is opened, remaining product can be stored in clean, food grade, labeled, and airtight containers... 8. Monitor length of storage of foods. Most prepared foods should be used or discarded within 7 days. ...Monitoring. ...Temperature Control: 1. Check the temperature of all refrigerators, freezers, and dry storerooms at the beginning of each day. 2. A designated associate or set of associates will check refrigerators daily to verify that foods are date marked, organized..., not exceeding the food storage timer [sic] period guidelines."

An observational tour conduced on May 27, 2021, with EMP1, EMP2, and EMP3 at 1:15 PM to 1:52 PM of the facility dietary department revealed the following:

An observation of perishable items in freezer "A" revealed an unsealed bag of frozen food resembling shredded chicken. Further observation revealed there was no label indicating the food type and no open and beyond use date on the bag.

An observation of perishable items in freezer "B" revealed the freezer contained opened packages of bagels, garden burgers, corn and carrots that was not labeled with open and beyond use dates. Further observation revealed the freezer thermometer was not working.

An interview conducted on May 27, 2021, at 1:25 PM with EMP3 confirmed the open bag of frozen food resembling shredded chicken in freezer "A" was not labeled with the food type, the open date and beyond use date as per facility policy. EMP3 said "I couldn't tell you what it is."

An interview conducted on May 27, 2021, at 1:38 PM with EMP3 confirmed the packages of bagels, garden burgers, corn and carrots in freezer "B" was not labeled with the food type, the open date and beyond use date as per facility policy and that the thermometer was not working. EMP3 stated "I thought this freezer was monitored centrally but it is not. The cord is cut. The thermometer is not working to record the freezer temperature."

Cross Reference:
111.14(3): Dry Storage




Plan of Correction:


The Dietary Supervisor conducted an audit and ensured that all items are labeled and dated according to the policy.


The Food Storage: Dry Goods Policy and The Labeling and Dating Policy was reviewed, updated and dated. All dietary employees will be re-educated on these policies by the Dietary Supervisor and it will be documented on the inservice record sign in sheet by November 21, 2022.

The Dietary Supervisor will audit the freezers 3xs a week to ensure food is properly stored and properly labeled and remediate as necessary.

The Executive Director and/or Designee will report the results of the audits to the Quality Assurance Performance Improvement Committee Monthly until 100% compliance is achieved for three months.


The Dietary Supervisor conducted an audit of the freezer temperature log to ensure that it was conducted according to the policy. Freezer B had a thermometer placed inside to monitor and record the temperature.

The Policy for Food Storage: Cold Foods was reviewed, updated and dated. All dietary employees will be re-educated on the policy by the Dietary Supervisor .

The Dietary Supervisor or Designee will inspect the temperature log 3xs a week to ensure the log has been completed and the temperature is in compliance.

The Executive Director and/or Designee will report the results of the audits to the Quality Assurance Performance Improvement Committee Monthly until 100% compliance is achieved for three months.



111.26 (b)(1)(2) LICENSURE
DISHWASHING

Name - Component - 00
111.26
(b) There shall be periodic checks at established intervals of:
(1) washing, rinsing, and sanitizing temperatures and cleanliness of machines and jets; and
(2) thermostatic controls

Observations:
Based on a review of facility policy, documents and interview with staff (EMP), it was determined the facility failed to monitor dishwasher temperatures at established intervals according to their policy.

Findings include:

A review of facility policy "Cleaning and Sanitizing Food Contact Surfaces" not dated revealed "Purpose: To prevent foodborne illness by ensuring that all food contact surfaces are properly cleaned and sanitized. ...Monitoring: ...3. In a dish machine, on a daily basis: ...Record the temperatures of the dish machine wash and final rinse temperatures three times per day."

A review on May 27, 2021, of facility document "Dishmachine Temperature Log" dated May 2021 revealed "Directions: 1. Complete this form prior to each meal. 2. Test thermal strip on a tray or plate after running through machine. 3. Record date, initials and temperature [sic]. 4. If temperatures [sic] are outside the acceptable range or the thermal strip does not reach 50 ppm, indicate corrective action on form. Further review revealed columns to record Wash and Rinse temperatures and Thermal Strip results for Breakfast, Lunch and Dinner each day of the month without readings. Further review revealed Wash and Rinse temperature readings was not recorded for Lunch on May 5, 2021, for Lunch on May 13, 2021, and no recordings for any meal after Breakfast on May 24, 2021 through May 27, 2021; The Thermal Strip column was without recordings for all meals.

An interview conducted on May 27, 2021, at 1:47 PM with EMP2 confirmed the "Dishmachine Temperature Log" dated May 2021 was not completed according to the facility's policy and instructions, and the Wash and Rinse temperature readings were not recorded from May 24, 2021, after Breakfast through May 27, 2021.





Plan of Correction:

Plan of Correction:

The Dietary Supervisor conducted an audit of the dish washer temperature log.

The Warewashing policy was reviewed, updated and dated. All dietary employees will be re-educated on the policy by the Dietary Supervisor and it will be documented on the inservice record sign in sheet by November 21, 2022.

The Dietary Supervisor or Designee will audit the dishwasher temperature logs daily and will remediate as necessary.

The Executive Director and/or designee will report the results of the audits to the Quality Assurance Performance Improvement Committee Monthly until 100% compliance is achieved for three months.






147.2 LICENSURE
MAINTENANCE OF SAFETY & SANITATION

Name - Component - 00
147.2 Maintenance of safety and sanitation

The hospital shall be equipped, operated, and maintained so as to sustain its safe and sanitary characteristics and to minimize all health hazards in the hospital, for the protection of both patients and employes.

Observations:
Based on observation, review of facility policies and interview with staff (EMP), it was determined the facility failed to maintain the linen storage closet in a safe and sanitary manner.

Findings include:

A review of facility policy "Housekeeping Cleaning Plan" dated September 2011 revealed "In an effort to maintain safety and sanitation, the hospital shall be equipped, operated, and maintained so as to sustain its safe and sanitary characteristics; and to minimize all health hazards in the hospital, for the protection of both patients and employees. ...Environmental rounds will be conducted monthly by the Director of Plant Operations, the Infection Preventionist, the CEO and the Housekeeping staff member responsible for the area. Repairs needed will be forwarded to the Maintenance Department for action."

An observation on May 27, 2021, at 2:30 PM of Room 241, the Linen Closet, revealed sheets and towels on a cart that was not covered. Further observation revealed four or five bags of linen on the floor that was noted to have floor tiles missing that exposed what appeared to be concrete and glue residue.

An interview conducted on May 27, 2021, at 2:32 PM with EMP3, confirmed there was sheets and towels on a cart that was not covered, four bags of linen on the floor and there was floor tiles missing that exposed what appeared to be concrete and glue residue.

An email communication recieved by the survey team on August 3, 2021, at 9:45 AM by EMP1 confirmed the facility had not replaced the missing floor tiles as of August 3, 2021.



















Plan of Correction:


An audit of all linen carts and linen closet was completed.

The tile in the linen closet room 254 was repaired in 2021.

The Linen Storage Policy was reviewed, updated and dated to reflect the new companies responsibility.
All Housekeeping Employees were inserviced by the Housekeeping Supervisor on the updated policy and it will be documented on the inservice record sign in sheet by November 21, 2022.

The Housekeeping supervisor or Designee will audit the linen closet 3x a week to ensure nothing is on the floor and remediate as necessary. The Housekeeping Supervisor will audit the linen carts 3x a week to ensure the carts are covered and remediate as necessary.


The Executive Director and/or Designee will report the results of the audits to the Quality Assurance Performance Improvement Committee Monthly until 100% compliance is achieved for three months.