INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on April 24, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Arc Manor (Kittanning) 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 personnel records, the facility failed to ensure that a counselor assistant provided documentation to the facility director that he is working toward counselor status in one of one personnel records.
The findings include:
Ten personnel records were reviewed on April 24, 2012. Counselor assistant documentation of working toward counselor status was required in one personnel record. The facility was unable to provide documentation that employee # 5 had provided documentation that he that he was working toward becoming a counselor.
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Plan of Correction
As mentioned in the earlier plan of correction, all supervisors met on April 26, 2012 following the exit interview. At that time, all staffing ratios for each appropriate level of care were reviewed. In addition, each supervisor was reminded of the language that needs to appear in supervision notes when it is determined that a Counselor Assistant has the ability to carry a full caseload and that the individual is working toward becoming a Counselor as defined by Licensing Regulations. Staff #5, the clinician in questions, will meet the criteria for a Counselor as of 5/9/2012 and the yearly performance evaluation will reflect that change in status. |
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 cold food being stored at or below 40F and frozen food being stored at or below 0F.
The findings include:
The physical plant was inspected on April 24, 2012 from 3:00 pm to 3:30 PM. Two refrigerators/freezers are provided for client food storage. There was no thermometer in one of the refrigerators/freezers combination. The facility failed to provide a means to take the the temperature of the freezer and keep record and determine if the frozen food is stored at 0F.
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Plan of Correction
This refrigerator/freezer unit was recently purchased by the agency and it was not noticed until the physical plant inspection that the unit did not have an indepedent thermometer to measure the freezer temperature. ARC Manor will purchase a thermometer for this freezer unit and have it installed no later than May 26, 2012.
This physical plant standard and ARC Manor's policy will be reviewed with ARC Manor's managers in the monthly meeting to occur on May 22nd, 2012. In addition, to prevent the recurrence of this issue, the Clinical Assistant Supervisor will review the procedure of checking temperatures for refrigerators and freezers in the monthly Clinical Assistant's meeting. |