INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on May 11, 2015, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Gaudenzia Focus 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.
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Plan of Correction
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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 a physical plant inspection, the facility failed to keep cold food at or below 40 degrees Fahrenheit.
The findings include:
A physical plant inspection was conducted on May 11, 2015. The facility failed to keep cold food at or below 40 degrees Fahrenheit. The thermometer in the kitchen refrigerator registered 50 degrees Fahrenheit at the time of inspection, which was conducted at 11: 40 AM.
In addition, the facility did not maintain a refrigerator temperature log which documented that the facility kept cold food at or below 40 degree Fahrenheit.
The findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation. The facility was previously cited for non-compliance on May 6, 2014.
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Plan of Correction
705.7(b)(5) Food Service
Focus House Director neglected to ensure that cold food in the refrigerator was kept below 40 F and noting the temperature of the refrigerator was being documented daily on each shift.
Focus House Director will ensure that the thermostat for all equipment that stores the residents' food is kept below 40 F and documented daily on each shift.
On May 11th, 2015 immediately following the DDAP site visit the Director purchased and placed a new thermostat inside the refrigerator.
Focus House Director neglected to ensure that the refrigerator log was maintained to document daily temperature.
On May 11th, 2015 during the DDAP licensing visit the Focus House Director placed the temperature log on the refrigerator to document daily temperature on each shift.
Focus House Director will review refrigerator log to ensure that the temperature is being maintained at 40 F daily.
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709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a physical plant inspection and an interview with the Facility Director, the facility failed to comply with the maximum approved capacity and failed to notify the Department within 90 days of a change in the authorized maximum capacity.
The findings include:
A physical plant inspection was conducted on May 11, 2015. The facility is licensed by the Division for a maximum client capacity for 12 inpatient non-hospital drug-free transitional beds.
Based on observation, the facility failed to ensure that 12 inpatient non-hospital drug-free transitional beds were set-up and ready for use. During an interview, the Facility Director stated that one bed was removed from the facility.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On June 18, 2015 Program Director submitted a letter communicating changes and reasons for changes for the 12 inpatient non hospital drug free transitional beds. Changes were made due to our CRRS Regulation 5310.73.e2 Physical Plant for fire codes and square footage.
Program Director will be responsible for communicating any changes to DDAP Licensing regarding facility's inpatient non hospital drug free transitional beds within 90 days of any changes. |