INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 4-5, 2016, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alcohol and Drug Abuse Services Inc., 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
There was no first aid coverage for the 12:00AM to the 8:00AM shift for residential treatment on the following days in 2016: July 3rd, 4th, 7th, 10th, 11th, 14th, 16th, and 17th
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Plan of Correction
The corrective action plan is that the Residential Worker who worked July 3rd, 4th, 7th, 10th, 11th, 14th, 16th, and 17th, will be trained in first aid on 9/13/16. Ongoing procedure will be that all new staff will be certified in first aid within 6 months of date of hire. Inpatient staff will not work alone without documentation of first aid training. The inpatient program manager will ensure that no staff will work alone and to verify that all trainings are completed. Training will be conducted by a certified CPR/First Aid trainer. |
705.7 (b) (2) 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:
(2) Clean and disinfect food preparation areas and appliances following each prepared meal.
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Observations
The facility does not have a process to sanitize pots and pans that are too large to fit in the dishwasher. The facility does not have a process to sanitize plastic bowls that would melt in the dishwasher.
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Plan of Correction
The Kitchen Staff that has been trained by ServSafe has been instructed by the Program Manager to utilize the ServSafe process of sanitizing any items that will not fit into a dishwasher. All items that fit in the dishwasher will continue to be sanitized through the dishwasher sanitation setting. The items will now be heated to at least 171 degrees Fahrenheit for at least 30 seconds. The Program Manager has posted the printout of the ServSafe documentation. All staff that works in the kitchen will initial the printout to ensure understanding. Program Manager will meet with Kitchen Staff on a weekly basis in order to ensure continued utilization of this procedure. |
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
The kitchen freezer temperature was tested at 5 degrees Fahrenheit.
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Plan of Correction
The Program Manager has instructed Kitchen Staff to follow the regulation that the freezer temperature is to be at 0 degrees Fahrenheit or below. The kitchen staff will continue to maintain a daily log of freezer temperature and the freezer will be monitored by Inpatient Program Manager on a weekly basis to ensure that temperature is maintain at the correct setting as well as to ensure that the log is kept in accordance to policy. |