INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 20, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New insights, 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 and a plan of correction is due on June 8, 2010.
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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 a review of the "Staffing Requirements Facility Summary Reports" for all of the facilities in the Project and interviews with the Project Director/ Facility Director 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 "Staffing Requirements Facility Summary Reports" for the two facilities that make up the project list a total of 13 counselors and/or counselor assistants who are fee-for-service employees and/or full or part-time employees. The total of the hours per week provided to the project by counselors and/or counselor assistants equated to 8.85 FTE counselor and/or counselor assistant positions within the project.
The "Staffing Requirements Facility Summary Reports" for each of the two facilities within the project revealed that no employee was listed as full-time clinical supervisors. A full-time equivalency of 8.85 counselors and/or counselor assistants requires a minimum of one full-time clinical supervisor within the project.
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Plan of Correction
Clinical Supervisor Qualifications. A newly hired Clinical Director is projected to be in place by August 31, 2010. This individual will meet all the qualifications for this role, of full-time clinical supervisor. This Clinical Director will have a maximum of (5) five drug and alcohol clients on their caseload. The Executive Director is responsible for this task and will also develop a job description for this new position. |
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of personnel records and conversation with the project/facility director, it was confirmed that the facility failed to demonstrate that a performance evaluation was conducted semi-annually for a counselor assistant..
The findings were:
Employee record #5 contained no performance evaluation for April /30/10. The record contained a documented performance evaluations for October 30,2009. A conversation with the facility director on May 20, 2010 at 1:20 P.M. confirmed that no performance evaluation was conducted semi-annually for Employee #5.
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Plan of Correction
Supervison of Counselor Assistant. Counselor assistant employed at the York office will be evaluated semi-annually. The evaluation scheduled for 4/30/2010 was completed on 5/25/2010 by the York office clinical suprvisor. The next evaluation is scheduled for 10/30/2010 to return to original semi-annual schedule. The clinical supervisor will be responsible for scheduling evaluations one month prior to 10/30/2010 and future scheduled semi-annual dates. The counselor assistant will continue to receive semi-annual evaluations until promoted to counselor when conditions on 704 (c) are met. |
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 a review of fiscal documents presented at the time of the inspection and an interview with the facility director, the facility failed to document an annual audit of financial activities for the year that ended June 30, 2009.
The findings included:
During the onsite licensing inspection conducted May 18, and 19, 2010, the fiscal documents were reviewed. The facility director was interviewed about the annual audit and it was confirmed the project had not completed an audit.
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Plan of Correction
The Executive Director will request an exception to the requirement for an annual audit. This request will be filed by June 11, 2010. If the exception is not granted, the Chief Financial Counsel will secure the services of an independent public accountant by July 31, 2010. The audit will be conducted with results reported to the PA Department of Health by September 30, 2010. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a review of the record keeping system during the onsite inspection of May 20, 2010, the facility failed to ensure that records were stored in locked containers.
The findings include:
During the May 20, 2010 inspection, the licensing specialists observed patient file cabinets that were located in a group room at the facility to be unlocked. The project failed to have the client records secured in a locked container.
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Plan of Correction
The archive file cabinets containing client records will be locked at all times except when archived filed are removed or placed in archives. The administrative manager will assure that files are locked and be responsible for removing files or placing files in archives. Keys to archived files will be held by the administrative manager. The Executive Director will add an addendum to policy regarding retention of client records in the York office which will be reviewed at staff meeting on 6/16/2010. |