INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 21, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, The Council of Southeast Pennsylvania, 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(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
The facility failed to ensure that the staff person hired to the project director position met the appropriate educational requirements prior to being hired. Employee #1 was hired as the project director on November 1, 2018. The documentation provided indicated that employee #1 has a Master's Degree in Professional Communication, which is non-qualifying for the position based on DDAP's Licensing Alert 01-19.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Letter of request for exemption sent by President of Board of Directors due to her credentials being comparable to those required in 28 Pa. Code 704.
At present, we have taken an initial step by requesting an exception for the credentials of the Project Director.
In the event that this request is denied, we will need to review alternatives within the executive team and have approval from the Board of Directors to make any changes to the person in this role. |
709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
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Observations
The facility failed to develop and implement a written policy and procedure that addressed the use of all medications by clients, based on the review of the facility's policy and procedure manual.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The medication policy and procedure was developed immediately after licensing visit and approved by the Board of Directors on March 29th, 2019. It is now part of our Policy and Procedure Manual. |