INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 11, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Insights II, 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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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
One staffing record was reviewed for the Project Director and Facility Director positions on January 9, 2017.
Employee # 1 was initially hired by the project on 1/1/16, and was promoted to both the Project Director and Facility Director positions on 8/16/16. The qualifications documented in the employee's record indicated that the employee completed a Bachelor's degree in Social Work. The resume documented in the employee's record indicated that the employee's prior work experience in human services did not include 3 years of experience in the area of Project Planning. Therefore, Employee # 1 did not meet the qualifications for the positions of Project Director and Facility Director.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Immediately following the site visit on January 11 by DDAP's licensing specialist, there was an active search for a qualified Project Director. As of February 6, 2017, there is a Project Director in place that possesses all qualifications for the position. The previous acting Project Director, or Employee #1 was made a Clinical Supervisor on the same date the replacement Project Director started at the project. The newly hired Project Director is a highly qualified individual with a Master's degree in Human Services and also holds a CADC. This person also has prior experience as both a Program Director at Pyramid Healthcare Methadone Clinic for one year and as Clinical Supervisor/Program Supervisor at Children's Home of York from 1998-2013; she meets all the requirements of Project Director listed under Chapter 704. This person will be functioning in a combined role of Project Director/Facility Director and will be responsible for overseeing both office locations without a facility director, her official title within the organization will be Project Director. |
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
One staffing record was reviewed for the Project Director and Facility Director positions on January 9, 2017.
Employee # 1 was initially hired by the project on 1/1/16, and was promoted to both the Project Director and Facility Director positions on 8/16/16. The qualifications documented in the employee's record indicated that the employee completed a Bachelor's degree in Social Work. The resume documented in the employee's record indicated that the employee's prior work experience in human services did not include 3 years of experience in the area of Project Planning. Therefore, Employee # 1 did not meet the qualifications for the positions of Project Director and Facility Director.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The qualification specifically regarding the requirement of having 3 years of program planning experience was misinterpreted by the Board of Directors, therefore permitting Employee #1 to be promoted into the position of project director. Effective immediately, the Chairman of the Board will ensure all applicants for the position of Project/Facility Director have clear documentation of 3 years experience in all components listed in the qualifications. Employee #1 was made a Clinical Supervisor on February 6 when a fully qualified individual started as Project Director. The Project Director will be responsible for the supervision of both office locations and function in a combined role of Project Director and Facility Director so both positions are being fulfilled. The Chairman of the Board and the Board of Directors were made aware of the issue in a special board meeting to discuss the specific qualifications of Project/Facility Director. This special board meeting was held on January 10, subsequent to the verbal exit survey by DDAP's licensing specialist on January 9. This special meeting of the Board was documented and includes notes of what was discussed. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
A physical plant inspection was conducted on January 11, 2017, at approximately 9:45 am. The facility failed to ensure that all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company, and documented with the appropriate tag.
A fire extinguisher was found to be marked with a sticker that indicated the fire extinguisher was last inspected in 2009. This fire extinguisher was located outside of a counselor's office, next to the entrance into the office.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The President of the company is ultimately responsible for ensuring all fire extinguishers are inspected and tagged correctly. All fire extinguishers owned by the project were inspected in June of 2016 and subsequently tagged correctly. The fire extinguisher mentioned in this citation may have had the correct up to date tag pulled off inadvertently as it is located in a common shared space. However, when notified that particular extinguisher was not up-to-date by the licensing specialist, the President immediately got a brand new fire extinguisher. This brand new extinguisher was purchased on January 11 from a local fire equipment company and immediately replaced the out-of-date fire extinguisher. The President did make an announcement to staff during staff meeting on January 19 that fire extinguisher tags need to be checked individually prior to the next licensing visit. |