INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on November 28 through November 29, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on December 22, 2006.
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Plan of Correction
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The hot water temperature registered at 125 Fahrenheit in the resident's bathroom on the second floor. There was no hot water in the staff bathroom on the first floor.
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Plan of Correction
Project Director will immediately contact contracted plumbing company to adjust the hot water temperature to at or below 120 Fahrenheit in both bathrooms. Plumbing company will be called to adjust the water temperature on an as-needed basis. |
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
The temperature of the freezer was recorded as being above 0 degrees Fahrenheit for 25 days during the last month.
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Plan of Correction
Project Director will immediately contact the contracted refrigeration company to adjust the freezer temperature to at or below 0 degrees Fahrenheit. The staff cook will maintain a temperature log to ensure the proper temperature. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Fire extinguisher training was not documented in four of twelve employee records reviewed, #2, 3, 4 and 7. Fire extinguisher training was documented late in three of twelve employee records reviewed, #5, 10 and 11.
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Plan of Correction
This was an oversight. The Facility Director will ensure that proper documentation for the fire extinquisher training will be completed and filed within the first seven days of employment. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
There was no documentation of training for emergencies in four of twelve employee records reviewed, #2, 3, 4 and 7. Training for emergencies was documented late in three of twelve employee records reviewed, #5, 10 and 11.
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Plan of Correction
This was an oversight. The Facility Director will ensure that the proper documentation for emergencies is completed and filed for all staff within the first seven days of employment. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Alternate exit routes were not used during the fire drills documented for the months of March 2006 through November 2006.
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Plan of Correction
The Facility Director will ensure that alternate exits will be utilized for fire drills. |