INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the July 8, 2013 through July 9, 2013 licensure renewal inspection. The follow-up inspection was conducted on January 3, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Interim House West 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 observation during the physical plant inspection, the facility failed to keep frozen food at or below 0 degrees Fahrenheit.
The findings include:
A physical plant inspection was conducted on January 3, 2014, at approximately 2:15 PM and 3:50 PM. The facility failed to maintain frozen food at or below 0 degrees Fahrenheit. The thermometer in the freezer and on the outside freezer door registered 20 degrees Fahrenheit at 2:15 PM and 10 degrees Fahrenheit at 3:50 PM.
The cook confirmed at the time of the physical plant inspection that the freezers' temperatures exceeded 0 degrees Fahrenheit.
This is a repeat citation. The facility was previously cited for non-compliance on 7/9/13.
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Plan of Correction
IHW facility manager will ensure that all frozen food temperature is kept at or below zero degrees at all times. The freezer was serviced on 1/13/14 by Atlantic Refrigeration. The thermometer read zero at the time of service however temperature sensor is located on the inner door of freezer and oftentimes records outside temperature. The freezer was found in good working order. The thermometer will be replaced on 1/21/14 to ensure compliance with this regulation. The facility freezer will be inspected quarterly to ensure it is in good working order. The freezer thermometer will continue to be checked daily to ensure they are also operable and reading accurately. The facility manager and program director will hold a residential assistant training to inform them of the new procedures and to ensure 709.7 standards are adhered to. The training will occur 1//24/14. The Program Director will monitor compliance on a monthly basis via supervision. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's fire drill log, the facility failed to conduct an unannounced fire drill at least once a month during one of five months reviewed.
The findings include:
On January 3, 2014, the facility's fire drill log was reviewed covering the period of August 2013 through December 2013. The facility failed to conduct an unannounced fire drill during the month of August 2013.
The Project Director confirmed the findings.
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Plan of Correction
The facility manager will ensure that IHW holds unannounced fire drills on a monthly during sleeping and waking hours. All drills will have a log indicating, date time, evacuation time, exit route used and number of persons in the facility. The program will continue to identify different evacuation routes as outlined by the fire department. The program director and facility manager will hold a staff and resident in-service to address this standard. Training will occur on 1/24/14 Compliance will be monitored by program director on a monthly basis.
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