INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on December 20, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Kensington Hospital 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, it was observed that the facility failed to store all garbage in a covered container. The trash bin located outside in the back of the facility was overflowing with boxes and the lid could not be closed.
This finding was reviewed with facility staff during the investigation.
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Plan of Correction
The Environmental Services Coordinator ordered a lid for the trash bin located outside in the back of the facility on 12/20/2021.
The lid will be installed by Maintenance on the trash bin upon receipt.
In order to assure future compliance, the Maintenance Supervisor will monitor the trash and recyclable bids daily to assure the lids are closed to completely cover trash and recylables. |
705.7 (b) (2) 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:
(2) Clean and disinfect food preparation areas and appliances following each prepared meal.
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Observations
Based on a physical plant inspection it was observed that the facility failed to clean and disinfect food preparation areas and appliances following each prepared meal.
There was food spilled and burnt on the inside of the oven and on the inside and outside of the oven door.
The deep fryer had what appeared to be scum on the surface of the oil, the oil was black and there was burn food on the surrounding surface area of the fryer.
Food particles were observed on the wall behind the stove.
These findings were reviewed with facility staff during the investigation.
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Plan of Correction
The CEO and Dietary Supervisor developed a formal Cleaning Schedule for the Dietary Department to include the following:
The oven is wiped down on a daily basis by the Dietary staff, however, a thorough cleaning of the oven (on the inside and outside) will be done by the Dietary Staff every Friday.
The deep fryer oil will be changed on a weekly (every Saturday).
The wall behind the stove will be thoroughly cleaned every Friday (at the time the oven is cleaned inside and outside.
In order to assure continued compliance, the Dietary Supervisor will monitor the above listed cleaning tasks weekly and report the findings to the Performance Improvement Committee Meeting on a quarterly 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
Based on a physical plant inspection it was observed that the facility failed to keep frozen food at or below 0 degrees.
It was observed that the freezer in the basement had a temperature of 10 degrees. After inspecting the freezer content and closing the freezer door, the temperature read 14 degrees. After having the door closed a few minutes, the temperature read 17 degrees.
This finding was reviewed with facility staff during the investigation.
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Plan of Correction
The Hospital Maintenance worker repaired the freezer in the basement on 12/20/2021.
In order to assure continued compliance, Maintenance will now monitor the freezer in the basement on a daily basis to assure it is at the proper temperature and in good working order.
The results of this monitoring will be documented on the Environment of Care Rounds Checklist and reported to the Performance Improvement Committee on a quarterly basis. |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection it was observed that the facility failed to store all food items off the floor.
There was a box of chicken, boxes of juice and a box of tomatoes stored on the floor inside the walk-in refrigerator in the basement.
There were three cans of sauerkraut observed on the floor in the pantry across from the kitchen.
These findings were reviewed with facility staff during the investigation.
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Plan of Correction
The Dietary staff removed the following items that were discovered on the floor inside the walk-in refrigerator in the basement to a shelf inside the walk-in refrigerator in the basement:
A box of chicken, boxes of juice and a
box of tomatoes.
The Dietary staff removed the following items that were discovered on the floor inside the pantry across from the kitchen to a shelf in the pantry
Three cans of sauerkraut.
In order to assure continue compliance, the Dietary Manager will now monitor the walk-in refrigerator in the basement and the pantry across from the kitchen on a daily basis to assure no food items on stored on the floor in either areas.
The results of this daily monitoring will be reported to the Performance Improvement Committee on a quarterly basis. |