INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 20-21-2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clem-Mar House, Inc. was found to be not 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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705.6 (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
Based on a physical plant inspection conducted on March 20-21, 2018, the facility failed to ensure that the water temperature in the downstairs staff bathroom did not exceed 120 degrees fahrenheit. When tested water temp gauge read 130 degrees.
This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clem-Mar House has corrected the problem in the water temperature. The plumber has installed a portable water mixing valve on to the water system. This will ensure the temperature will remain at 120 degrees throughout the building. The maintenance man will monitor the water temperature on a weekly basis for any problems in temperature. Should a problem occur, he will notify the clinical director who will contact the plumber to resolve the issue. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the fire drill log for drills conducted between January 31, 2017 and January 31, 2018, the facility was unable to provide documentation of overnight sleeping fire drills being conducted every 6 months. The only documented drill during sleeping hours was conducted on 05/28/17 at 12:05 am.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director held a staff meeting with all resident managers on the importance of conducting fire drills during sleeping hours at least every six months. The head Resident Manager will monitor this issue monthly to ensure compliance with this regulation. The Clinical Director will also monitor this area on a regular basis. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records on March 21 - 22, 2018, the facility failed to ensure that each counselor completed at least 25 clock hours of training during the training year.
The facility was only able to provide documentation for 21 hours of training for staff person #3 during the 7/1/16-6/30/17 training year.
This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director met with the counselors and discussed the importance of obtaining 25 hours per year of accepted training. The Clinical Team Lead will review all training folders once per month to ensure compliance with this regulation. |