INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 30, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Children's Service Center of Wyoming Valley 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide close supervision by a trained counselor or clinical supervisor for the first 6 months of employment.
Employee #10 was hired on November 6, 2023 and was still employed at the time of the inspection. She had no documentation of close supervision.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
In accordance with 704.9(c )and licensing alert 4-02 any staff member qualifying as a counselor assistant will receive documented close supervision by their clinical supervisor weekly until meeting the qualifying time frame based upon their degree. This has been reviewed with all supervision staff and was implemented immediately. All counselor's assistants were notified of the change in supervision at the clinical staff meeting held on 2/9/2024 |
705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical plant inspection, the facility failed to maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. The basement did not have a fire extinguisher.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
In accordance with 705.28. Fire Safety. A portable fire extinguisher with a minimum of an ABC rating has been installed in the basement of the facility on January 31, 2024. |