INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 16, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc/Daniel Snow House 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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704.6(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 Report forms for all of the facilities within the drug and alcohol treatment project, the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The Staffing Requirements Facility Summary Report forms for the drug and alcohol treatment project's ten facilities were reviewed December 14 - 18, 2015. The project employs a total of 26.01 full-time counselors and counselor assistants. This number of full-time counselors and counselor assistants would require a minimum of 3 full-time clinical supervisors. The project currently employs 2 full-time clinical supervisors, as of December 18, 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A current Clinical Supervisor (residential) who was carrying a caseload of clients has had the caseload removed and will carry no more than one client at any time in the future. This will increase the number of Clinical Supervisors in the project. The Program Supervisor (residential) will assure the clinical supervisor is not tasked with a case load of more than 1 client at any given time.
Division Director will also hire an additional Clinical Supervisor for the project. Division Director will also make sure that the project is in compliance moving forward.
Division Director will make sure the project will have one clinical supervisor for every 8 FTE counselors/counselor assistants.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
A review of the fire drill logs was conducted on December 16, 2015. Documentation of a fire drill conducted during sleeping hours is required once every six months. The facility's sleeping hours were documented as Monday- Friday up at 6:30 AM. Saturday up at 7:30 AM and Sunday up at 8:30 AM. Lights out at 11:30 PM on Sunday- Thursday. Lights out at 12:30 AM on Friday and Saturday. There was no documentation of fire drills being conducted during the sleeping hours from December 2014 to November 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Program Director will make sure to schedule a fire drill during sleeping hours a minimum of once every six months. Program Director will assure these drills get documented on the fire drill forms and log. |