INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 28, 2011 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site inspection, Rehab After Work 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 and a plan of correction is due on March 29, 2011.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on the review of the " Staffing Requirements Facility Summary Reports " completed by each facility in the Project, and based on interviews with each facility director in the Project, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the Project.
The findings include:
From February 10 through March 3, 2011, the " Staffing Requirements Facility Summary Reports " for each of the thirteen facilities that make up the Project were reviewed. The " Staffing Requirements Facility Summary Reports " list a combined total of 41 counselors and 12 facility directors who are providing drug and alcohol counseling. The total number of drug and alcohol counseling hours per week provided by the counselors and facility directors equates to 39.6 FTE counselors within the project, and therefore the project is required to have at least four full-time clinical supervisors and one part-time clinical supervisor or lead counselor. The " Staffing Requirements Facility Summary Reports " did not identify a full-time clinical supervisor at any of the Project ' s thirteen facilities.
From February 10 through March 3, 2011, interviews with each facility director in the Project were conducted during their respective licensing inspection. Each facility director confirmed that the Project does not have a full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the Project.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to document fire extinguisher training upon staff employment.
The findings include:
Two personnel records were reviewed on February 11, 2011 to verify that staff had been instructed in the use of a fire extinguisher upon employment.
The facility failed to document the completion of fire extinguisher training upon staff employment in personnel record # 2.
Employee # 2 was hired March 25, 2010.
The training was due upon employment, the training was documented on April 5, 2010.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
The findings include:
Two personnel records were reviewed on February 11, 2011 to verify that staff had been trained to perform assigned tasks during emergencies.
The facility failed to ensure that personnel on all shifts were trained to perform assigned tasks during emergencies.
Employee # 2 was hired March 25, 2010.
The training was not documented until April 5, 2010.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on the review of administrative records and an interview with the Facility Director, the project failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
On February 11, 2011 the project's administrative records were reviewed for a financial audit following the end of their fiscal year. The project's 2009 fiscal year ended on December 31, 2009, but the independent financial audit for this period was not documented at the time of review.
An interview with the Facility Director on February 11, 2011 confirmed that the financial audit had not been documented following the end of the fiscal year.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |