INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and for the approval to use a narcotic agent, specifically buprenorphine in the treatment of narcotic addiction. The inspection was conducted on April 21-22, 2015, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Malvern Institute- Malvern 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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705.2 (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 store all trash, garbage, and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A physical plant inspection was conducted on Tuesday April 21, 2015 at approximately 3:30pm. The trash cans in the kitchen preparation area did not have lids to prevent the penetration of insects and rodents.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The maintenance and dietary staff will be trained on the importance of keeping trash cans in the kitchen area covered with a lid to prevent the penetration of insects and rodents. This education will be documented.
Lids have been purchased for all trash receptacles in the kitchen preparation area.
The dietary and/or maintenance supervisors will conduct daily checks to ensure lids are secure on all trash receptacles. |
705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection the facility failed to store utensils in a clean enclosed area.
The findings include:
A physical plant inspection was conducted on April 21, 2015 at approximately 3:30pm. Cooking utensils were stored in an open area on hanging racks located above the sink in the food preparation area. All eating, drinking and cooking utensils must be stored in a clean, enclosed area. Pots and pans may be stored on hanging racks.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Dietary staff will be trained on the importance of storing all eating, drinking and cooking utensils in a clean, enclosed area. This education will be documented.
Clear plastic storage bins with lids were purchased and are being used for all utensil storage. The utensil rack was disposed of to avoid any recurrence.
The Dietary Supervisor will do daily checks to ensure these storage bins are being used properly. |