INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensure inspection that was conducted on September 19-20, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from the on-site inspection, Kensington Hospital Outpatient Treatment Program, 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 supervisory review:
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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" (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 SRFSR for the two facilities that make up the project list a total of 9.48 FTE counselor positions within the project.
The SRFSR for the two facilities within the project revealed that no employees were listed as a full-time clinical supervisor. The SRFSR listed one part time clinical supervisor who worked 20 hours per week in at the project and had a full caseload..
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Plan of Correction
A new Director of Behavioral Health Services was hired for the Outpatient Treatment Program 11/30/17. This full-time Director now supervises 8 full-time counselors.
With the hiring of this full-time Director, the Clinical Supervisor of the Kensington Hospital Detox unit can now supervise the three (3) full-time counselors according to State regulations. The Clinical Supervisor does not have a patient caseload. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to provide documentation of TB/STD training in one of two personnel records reviewed where applicable. The TB/STD training documentation was due by 4-14 -2017. TB/STD training documentation was not available at the time of the September 20, 2017 annual inspection.
These findings were reviewed with the facility staff during the licensing process
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Plan of Correction
Kensington Hospital's Clinical Supervisor met with counselors and reminded them they must obtain the State mandated trainings (HIV/AIDS, TB/STD and Confidentiality).
All Counselors will have the mandated trainings completed by 2/28/2018.
The Clinical Supervisor will develop a form indicated the employee's hire date and monitor the time frames for any mandatory trainings so that trainings will be completed by the due dates. |