INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 5, 2006 through June 9, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on July 6, 2006.
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Plan of Correction
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The dates on the updates in client files #11 and #12 did not reflect the actual date that they were written, but instead reflected the dates that they were due.
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Plan of Correction
Executive Director will review this specific regulation with the Clinical Director to ensure that the regulation is followed. The Clinical Director will sign and date the treatment plan updates on the actual date they were reviewed. The Executive Director and the Evaluation and Monitoring Committee of ARC Manor's Board of Directors will ensure compliance with this standard. |
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 temperature for the hot water in the first floor bathrooms was 126 degrees Fahrenheit.
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Plan of Correction
Assistant Director will notify the agency's Maintenance staff to adjust the hot water tank to the allowable temperature. The agency's custodial worker will be trained to check the hot water temperature in the first floor restrooms once a week. This will be documented and reported to his supervisor. If the temperature does exceed the allowable level, the Maintenance staff will be contacted in order to correct the temperature. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Counselor assistant #1 has a Bachelor's degree, but not the required experience. The requirement of six months of close supervision was documented, however, seven weeks of direct observation was not included.
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Plan of Correction
Clinical Director will do observation of clinical activities for Counselor Assistant #1 for seven weeks in order to complete the six month close supervision requirement. Clinical Director will provide documentation of this observation to the Executive Director on a weekly basis until completion. |