INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 4, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site 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:
|
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 observations on June 4, 2014, the facility failed to keep frozen food at or below 0 degrees F.
The findings include:
A physical plant inspection was conducted on June 4, 2014. It was observed during the inspection at approximately 10:57 A.M. and 2:19 P.M. that the thermometer on the outside freezer door and the two thermometers inside the freezer read a temperature of 10 F degrees.
The findings were confirmed during an interview with the facility manager on June 4, 2014 at approximately 2:20 P.M.
This is a repeat citation. The facility was cited on January 3, 2014 and July 9, 2013 for noncompliance with this standard.
|
Plan of Correction
The facility manager will ensure that the temperature for the freezer will be read zero or below at all times. Atlantic Refrigeration replaced unit and will inspect it quarterly to ensure freezer is in good working order. The residential assistants and kitchen team will be trained on the use of the new unit and location of thermometers on 6/26/14.
The facility manager will inspect the unit daily and record temperature as required for this regulation. Compliance with 705.7 will be monitored by the program director and PHMC's facility operations director.
|
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
|
Observations
Based on a review of the project's annual audit, the project failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services by the end of the fiscal year.
The findings include:
The Project's fiscal year runs from July 1 through June 30.
The document provided by the facility and identified as the annual audit was reviewed on May 22, 2014 and June 4, 2014. The financial audit was to be completed by the end of the fiscal year. The document presented as the project's annual audit for the 2012 to 2013 fiscal year was completed on January 21, 2014. However, the signed and dated accountant's report included in the document stated, "We have reviewed the accompanying statements of financial position of Interim House West Facilities, Inc. (the "Company" ) as of June 30, 2013 and 2012, and the related statements of activities and changes in net assets, and cash flows for each of the years then ended. A review includes primarily applying analytical procedures to management's financial data and making inquiries of company management. A review is substantially less in scope than an audit, the objective of which is the expression of an opinion regarding the financial statements as a whole. Accordingly, we do not express such an opinion." The document offered as the audit for the 2012 to 2013 fiscal year did not meet the requirements.
The findings were reviewed with the clinical director during an interview on June 6, 2014 at approximately 3:45 P.M. The clinical director did not dispute or confirm the findings.
|
Plan of Correction
PHMC/IHW audit report will be completed and available by January 31, 2015. The program director will forward an electronic copy of the report to inspector to ensure compliance with this regulation. IHW's controller will alert auditors that IHW is required to have the audit completed no later than six months after the close of the fiscal year.
Program Director and Deputy Operations Director will monitor compliance with regulation at our quarterly finance meetings.
|