INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 5-8, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. 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:
|
Plan of Correction
|
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.
|
Observations
Based on a physical plant inspection, the facility failed to keep cold food at or below 40 degrees Fahrenheit.
One refrigerator, located in the basement, used to store client ' s food, was reading 47 degrees Fahrenheit at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All food has been removed from this refrigerator and is being stored in two other refrigerators and a freezer at the program. The need for another refrigerator will be discussed with program management and a decision will be made by 10/31/23. Temperature Logs will be completed and monitored on a daily basis. All staff will be trained by CQI Manager on proper procedures for checking the temperature, what the target temperatures are, and how to properly complete the log. This training will occur no later than 10/31/23 and will be documented via a sign in sheet. The Program Director will review the logs on a monthly basis, and the CQI Manager will review on a quarterly basis to ensure that they are accurate and in compliance. Any issues noted will be brought to the attention of program management to be addressed immediately. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
Fire drill records were reviewed from July 2022 through June 2023. The facility failed to conduct a physical fire drill during the months of December 2022, February 2023, and June 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Deputy Director will review the DDAP regulations and internal policies with the Program Director in a documented supervision. The Program Director and Operations Manager will retrain all staff on the procedures for fire drills and review the DDAP regulations and internal policies. The training will occur by 10/31/23 and will be documented via sign in sheet. The Fire Drill Log will be reviewed by Program Director each month, and by the CQI Manager quarterly to monitor for compliance. Any issues noted will be brought to the attention of program management to be addressed immediately. |