INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 5, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Service and Children's Aid Society 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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704.11(f)(1) LICENSURE Counselor's Trng Req
704.11. Staff development program.
(f) Training requirements for counselors.
(1) Subject areas for training shall be selected according to the training plan for each individual.
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Observations
Seven personnel records were reviewed on October 5, 2016. Two out of seven personnel records pertained to counselors and were reviewed for annual training. The facility's training year is from July through June. The facility failed to document 25 clock hours of annual training for employee #4 for the July 1, 2015 - June 30, 2016 training year.
Employee # 4 is a counselor and was hired on March 2010. Employee record # 4 only contained documentation of 12 clock hours of annual training for the July 1, 2015 - June 30, 2016 training year.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The D&A Program Director met with employee #4 to discuss the required training hours required per year. We reviewed his 2016/17 training plan and discussed other trainings of interest. Between the employee and Program Director we will schedule, (employee #4)attend and complete at a minimum the required 25 hours for the year. On Monday, October 24th 2016 a clinical staff will be held and all staff will be reminded of this requirement of training by the D&A Program Director. This corrective action will be completed by the date of 10/24/16. |
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 physical plant inspection was conducted on October 5, 2016. During the inspection of the facility restrooms the hot water temperature in the third floor restroom was measured at 123 degrees F.
These findings were reviewed with facility staff.
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Plan of Correction
On October 5th 2016 the City of Franklin's Fire Department was notified of the increased hot water temperature (123) in Suite 301's restroom and it needed to be turned down. The fire department personnel turned down the water and at the next check approximately 1.5 hours later it was down one degree to 122. This writer D&A Program Director will purchase a thermostat by October 21st and test the water temperature and if not down to required level the Fire Department will be notify to come and readjust. The water temperature will be randomly checked by the Program Director to make sure we stay in compliance. The thermostat was purchased on 11/21/16 for the use of testing the water temperature. |