INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 4 through 7, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Butler Regional Recovery Day 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 inspection and a plan of correction is due on May 6, 2011.
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Plan of Correction
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704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(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 clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on the review of the "Staffing Requirements Facility Summary Reports", a review of employee personnel records and a discussion with the facility director, the Project failed to ensure that each clinical supervisor met the qualifications for that position in one of two personnel records.
The findings include:
On April 4, 2011 four personnel records were reviewed. Two personnel records were required to have documentation of the qualifications for the position of clinical supervisor. The facility failed to provide documentation of clinical supervisor qualifications in personnel record #2.
Employee #2 was designated as a clinical supervisor in March 2011. Employee #2 had a Bachelor degree in Nursing. Per regulation a clinical supervisor shall meet at least one of the following qualifications specified in 704.6 (b) (1)-(4) . Employee #2 does not meet the qualifications for clinical supervisor.
This was discussed with the facility director throughout the licensing inspection and confirmed at the time of the exit meeting on April 7, 2011. The facility director explained that this designation was due to restructuring of administrative staff within the hospital.
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Plan of Correction
The staff member in question, Clinical Manger, will clinically manage the nursing staff and retain administrative oversight of Coordinator of D&A services and the programs. Coordinator will report to Vice President of Patient Care Service for Therapy Supervision. This is effective immediately. |
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of the "Staffing Requirements Facility Summary Reports", a review of employee personnel records and a discussion with the facility director, the Project failed to ensure that each clinical supervisor completed a core curriculum training in clinical supervision in one of two records.
The findings include:
Employee record #2 was designated by the Project as a clinical supervisor in March of 2011. Per regulation clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
A review of employee personnel record # 2 did not contain documentation of completion of a core curriculum in clinical supervision.
This was discussed with the facility director on April 4, 2011 and confirmed at the time of the exit meeting on April 7, 2011.
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Plan of Correction
The staff member in question, Clinical Manger, will clinically manage the nursing staff and retain administrative oversight of Coordinator of D&A services and the programs. Coordinator will report to Vice President of Patient Care Service for Therapy Supervision. This is effective immediately. Therefore, the person in this position would not be required to receive this supervision. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of the "Staffing Requirements Facility Summary Reports", a review of employee personnel records and a discussion with the facility director, the Project failed to ensure that each clinical supervisor participated in documented monthly meetings with their supervisor to discuss their duties and performance in the first six months of employment in that position in one of two personnel records.
The findings include:
Per regulation clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance in the first six months of employment. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
Employee #2 was designated by the Project as clinical supervisor in March of 2011. A review of employee personnel record # 2 did not contain documentation of monthly meetings with the supervisor.
This was confirmed with the facility director on April 4, 2011 and at the time of the exit meeting on April 7, 2011.
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Plan of Correction
The staff member in question, Clinical Manger, will clinically manage the nursing staff and retain administrative oversight of Coordinator of D&A services and the programs. Coordinator will report to Vice President of Patient Care Service for Therapy Supervision. This is effective immediately. Therefore, the person in this position would not be required to receive this supervision. |