INITIAL COMMENTS
|
This report is a result of a review of the final written reports of the on-site licensure inspections that were conducted from March 6 - 26, 2013, by staff from the Program Licensure Division. Based on the final review of the findings from the on-site inspections, 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 final review:
|
Plan of Correction
|
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.
|
Observations
Based on a review of the "Staffing Requirements Facility Summary Reports" (SRFSR) for all of the facilities 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:
The SRFSRs for the fifteen facilities that make up the project list a total of 68 counselors (some full time and some part time) and fifteen part-time clinical supervisors. In addition eleven of those part-time clinical supervisors served as counselors carrying a caseload above five clients. The total of the hours per week provided to the project by counselors and clinical supervisors carrying a caseload equates to 55 FTE counselor positions within the project.
The SRFSRs for the fifteen facilities within the project revealed that no employees were listed as a full-time clinical supervisor. The SRFSR listed each of the fifteen part-time clinical supervisors as facility directors; therefore they are unable to provide full-time clinical supervision. A full-time equivalency of 55 counselors would require a minimum of 6 full-time clinical supervisors and one part-time clinical supervisor within the project.
This finding was confirmed with the project director during the administrative review.
|
Plan of Correction
The facility has requested an exemption to licensing standard
704.6(a). The Executive Director will develop and implement the necessary protocols in order to ensure 100% compliance with the requested exemption. |