INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 27 and 28, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Roxbury 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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705.7 (b) (1) 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:
(1) Have a food preparation area with a refrigerator, a sink, a stove, an oven and cabinet space for storage.
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Observations
Based on the physical plant inspection, the facility failed to ensure that food was stored off the floor.
The findings were:
The physical plant inspection took place on January 28, 2016 at around 2:00 pm. The inspection revealed that there were three boxes with food in them located on the floor in the walk-in-freezer. The freezer is located in the kitchen beside the cafeteria.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The three boxes that were found to be on the floor in the walk in/freezer were immediately removed from the floor and placed on shelving in the walk in/freezer on 1/28/16. The Director of Plant Operations will provide re-education to all dietary staff regarding the proper storage of food items within the kitchen and its associated areas. This re-education will be completed by March 18, 2016. The Director of Plant Operations will add daily assessment of the proper storage of food items to the dietary checklist and will also provide random checks of the kitchen and its associated areas to ensure that no food or other items are stored on the floor at any time. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consents in one of ten records reviewed.
The findings include:
Six client records were reviewed on January 27, 2016. All were reviewed for informed and voluntary consent forms. The facility failed to document if the client was offered a copy of the informed and voluntary consent forms.
Client #6 - The facility failed to document on the consent to release, dated January 16, 2016 for the client's family member, whether or not the client was offered a copy of the consent.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The consent for client #6 was immediately corrected on 1/28/16 and the client refused a copy of the consent to be provided, which was noted on the consent to ensure it was fully completed. The Clinical Supervisor will provide re-education to all clinical staff regarding proper consent completion to ensure that thoroughly completed, informed and voluntary consents are obtained from all patients. The Director of Nursing will provide re-education to all nursing staff regarding proper consent completion to ensure that thoroughly completed, informed and voluntary consents are obtained from all patients. The Director of Admissions will provide re-education to all admissions staff regarding proper consent completion to ensure that thoroughly completed, informed and voluntary consents are obtained from all patients. All re-educations will be completed by March 18, 2016. The Clinical Supervisor will perform a monthly random audit of the consents in 20 charts and the results will be reported monthly to the Performance Improvement Committee until a desired compliance rate of 90% or higher is reached for three consecutive months. |