INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on August 14-15, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Catholic Charities Diocese of Harrisburg, PA, 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:
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Plan of Correction
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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the facility failed to document that a counselor assistant was working toward meeting the qualifications for the position of counselor in one of one record.
The findings include:
Six personnel records were reviewed on August 14, 2012. One personnel record pertained to the position of counselor assistant. The facility failed to provide documentation that the counselor assistant was working toward meeting the qualifications for the position of counselor in staff record # 3.
Employee # 3 was hired on May 10, 2007. Employee # 3 did not provide documentation by December 31, 2011, that she was working toward counselor status.
This finding was reviewed with the Facility Director and not disputed.
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Plan of Correction
As part of the regular six month evaluations an attachment will be designed which will allow the Counselor Assistant to list her progress towards meeting the requirements for Counselor Assistant Promotion. This form will be designed and attached by the Program Director and reviewed every 6 months. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the policy and procedure manual and personnel training records, the facility failed to ensure that training feedback was completed in one of six records reviewed.
The findings included:
The facility policy and procedure manual and six personnel records were reviewed on August 14, 2012. The policy indicated personnel are required to complete feedback on training within 72 hours of completion. All personnel records were reviewed for training feedback documentation.
Personnel record #1 failed to document feedback on two trainings, 3/20/2012, and 9/12/2011.
The findings were reviewed with the Facility Director and were not disputed.
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Plan of Correction
The Program Director will make sure the Training Feedback Form is made available to each employee, even off site personnel. The Program Director will make sure the Training Feedback Form is completed for each training counted towards each employee's training requirements. The Director of Administration will oversee the Training Feedback Form is completed for offsite personnel. |
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 an inspection of the physical plant, the facility failed to provide documentation of frozen food being stored at or below 0 F.
The findings include:
The physical plant was inspected on August 15, 2012, from 3:30 p.m. to 4:30 p.m. A freezer in the pantry area did not have a thermometer or a documented temperature log. There was no way to determine if the frozen food was stored at or below 0 F.
This finding was confirmed with the Facility Director and not disputed.
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Plan of Correction
Extra thermometers will be available onsite so when new equipment such as the freezer in question arrives or is placed in to operation, a thermometer can be placed immediately in the freezer or refrigerator. The Program Director will keep thermometers supplied. It will continue to be second shifts responsibilities to report any temperature concerns or lack of thermometers. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill log, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
A review of the fire drill log was conducted on August 15, 2012. The fire drill log was reviewed since the move to this location in June 2012. A fire drill was completed for July 2012 and did not include documentation of setting off the fire alarm or a smoke detector.
This finding was reviewed with the Facility Director and not disputed.
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Plan of Correction
The facility was unable to set off the alarm without interrupting two other programs who share the building. The program is new to the building. An Exception was submitted to the Department requesting to do manual or simulated fire drills. The Exception was approved August 15, 2012. The Program Director will make sure a simulated fire drill is completed as scheduled and a maintenance report kept on file at the program or the Administrative Offices for Department review. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records, the facility failed to provide results of reference checks in two of four personnel records.
The findings included:
Six personnel records were reviewed on August 14, 2012. Four personnel records were reviewed for documentation of reference results. The facility failed to document the results of reference checks in personnel records # 4 and 5.
Employee # 4 was hired on December 22, 2011. The application for employment listed three references. There was no documentation of contact with the references or any results.
Employee # 5 was hired on August 18, 2011. The application for employment listed three references. There was no documentation of contact with the references or any results.
The findings were reviewed with the Facility Director.
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Plan of Correction
A Reference Check Form has been designed and will accompany each application for hire. The Program Director will make sure this form is completed before any application for hire is processed for hire. The form will be placed in each employees personnel file attached to their application. |
709.26(d)(5)(ii) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(ii) The individual shall be informed, by written copy, of their annual evaluation.
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Observations
Based on a review of personnel records, the facility failed to document the employee was informed of their work performance evaluation in one of six personnel records.
The findings include:
Six personnel records were reviewed on August 14, 2012. Work performance evaluations were reviewed for all records. The facility failed to document that the employee was informed of their work performance evaluation in personnel record # 1.
Employee # 1 was hired on May 3, 2004. The work performance evaluation was completed on July 9, 2012. There was no documentation that the employee was informed of their work performance evaluation.
This finding was reviewed with the Facility Director and not disputed.
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Plan of Correction
The Director of Administration will make sure that off site personnel have a Performance Evaluation in each personnel file each year. The Program Director will follow up with this requirement each year. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of personnel records, the facility failed to document a written job description which contained the employee's and supervisor's dated signatures in one of four personnel records.
The findings include:
Six personnel records were reviewed on August 14, 2012. Four records were reviewed for documentation of a signed job description. The facility did not document a signed job description in personnel record #3.
Employee # 3 was promoted to counselor in June 2012. There was no documentation of a signed job description for counselor in the record.
The findings were reviewed with the Facility Director.
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Plan of Correction
The Program Director will make sure all personnel sign a Job Description Sign Off Page at the time of hire. The Form will be part of the Hiring Packet and presented at the time of hire to prevent this citation in the future. |