INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection, conducted on October 6 - 8, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Parkside Recovery 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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705.25 (5) LICENSURE Food service.
705.25. Food service.
A nonresidential facility may provide meals to clients through onsite food preparation areas, a central food preparation area or contractual arrangements with vendors or caterers. A nonresidential facility which 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 F, hot food at or above 140 F, and frozen food at or below 0 F.
The findings include:
A physical plant inspection was conducted on October 8, 2014 from approximately 10:00 A.M. to 11:00 A.M. The Licensing Specialist asked to see a cold food, a frozen food, and a hot food temperature log during the inspection. A cold food, a frozen food, and a hot food temperature log were not presented for review. Therefore, the facility failed to demonstrate that cold food was kept at or below 40 F, frozen food was kept at or below 0 F, and hot food at the facility had been kept at or above 140 F.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All hot food temperature's will be taken and logged daily on a grid. A clinical supervisor will be responsible to take the temp and enter it on the grid to ensure this deficiency does not re-occur. The freezer used to store food has a thermastate installed which will be monitored by the facilty manager daily to ensure that this deficiency does not re-occur. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document fire extinguisher training upon employment for employee # 3.
The findings include:
Employee # 3, a counselor, was hired on 9/2/14. Employee # 3's personnel record was reviewed on 10/6/14 to verify the completion of fire extinguisher upon employment. The facility failed to ensure the completion of fire extinguisher training for employee # 3.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All new hires will be trained onsite at Parkside Recovery on the proper way to use a fire extinguisher. This will be done and documented within the first week of their start date. Employee #3 will be trained in the proper way to use a fire extinguisher before the end of the day Monday, October 27, 2014. The training supervisor will be responsible to ensure this deficiency does not re-occur. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that employee # 3 was trained to perform assigned tasks during emergencies.
The findings include:
Employee # 3, a counselor was hired 9/2/14. Based on a personnel record review on 10/6/14 the facility failed to ensure that employee # 3 was trained to perform assigned tasks during emergencies.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All new hires will be trained onsite at Parkside Recovery on their assigned tasks during emergencies. This will be done and documented within the first week of their start date. Employee #3 will be trained to perform her assigned tasks during emergencies by the end of the day Monday, October 27, 2014. The training supervisor will be responsible to ensure this deficiency does not re-occur. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on observations during the physical plant inspection, the facility failed to secure client records within locked storage containers.
The findings include:
A physical plant inspection was conducted on October 8, 2014 from approximately 10:00 A.M. to 11:00 A.M. It was observed during the inspection that the room directly outside of the discharge record's storage room was unlocked and included several discharged records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All discharged records were removed from the room noted in the observation and placed in a locked storage room by the Medical Records Supervisor. The Medical Records Supervisor will make weekly rounds to ensure all records are kept only in a locked room to ensure this deficiency does not re-occur. |