INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on February 24, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services Reading Psychiatric 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 March 17, 2010.
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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 " for all of the facilities in the Project and interviews with the Project ' s administrative staff, 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 " Staffing Requirements Facility Summary Reports " for the nine facilities that make up the project list a total of 59 counselors and/or counselor assistants who are fee-for-service employees and/or full- or part-time employees. The total of the hours per week provided to the project by counselors and/or counselor assistants equates to 30.69 FTE counselor and/or counselor assistant positions within the project.
The " Staffing Requirements Facility Summary Reports " for each of the nine facilities within the project revealed that no employees were listed as full-time clinical supervisors. A full-time equivalency of 30.69 counselors and/or counselor assistants requires a minimum of 3 full-time clinical supervisors within the project.
The Executive Director is listed as the Project Director (designated as employee # 1 for facility number 367070) and as the Facility Director for facility numbers 227059, 387012, and 677044 and cannot also act as a full-time clinical supervisor. The person listed as the Facility Director for facility numbers 067079, 217049, 017068, 367070 and 067058 (designated as employee # 2 for facility number 367070) cannot also act as a full-time clinical supervisor. The person listed as the Facility Director and clinical supervisor for facility number 387019 (designated as employee # 2 for facility number 387019) cannot also act as a full-time clinical supervisor.
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Plan of Correction
Pennsylvania Counseling Services submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State laws relating to drug and alcohol
treatment. This Plan of Correction should not be construed as either a
waiver of the facility's right to appeal or an admission of past or
ongoing violations of applicable regulatory requirements.
The Vice President of Quality Improvement and Director of Quality Improvement will ensure that there is one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors and/or counselor assistants in the entire Project. The Vice President of Quality Improvement and Director of Quality Improvement will ensure that these supervisors meet DOH staffing regulations for the position of full-time Clinical Supervisor. The Vice President of Quality Improvement and Director of Quality Improvement will also ensure that the Staffing Requirement Facility Summary Reports are completed accurately to reflect these supervisory hours for future inspections.
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical plant inspection the facility failed to ensure that the water temperature did not exceed 120F.
The findings include:
A facility plant tour was conducted on February 24, 2010 at 9:30 a.m. The facility failed to ensure that the hot water temperature did not exceed 120F. The hot water temperature was observed to be 130F.
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Plan of Correction
The PCS Maintenance Department modified the hot water temperature so that it does not exceed 120F. The Director of Maintenance will oversee that the water temperature is monitored periodically to ensure that it does not exceed 120F. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to ensure an individual treatment and rehabilitation plan shall be developed with a client.
The findings include:
Nine outpatient client records were reviewed on February 24, 2010. Comprehensive treatment and rehabilitation plans and treatment plan updates were required in the nine client records. The facility failed to have the client sign the comprehensive treatment plan in client records # 1, 8, and 9. Additionally, the facility failed to have the client sign the treatment plan updates in client records # 1, 4, 5, 6, 8, and 9.
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Plan of Correction
The Facility Director will oversee that staff are re-educated during staff meeting regarding the importance of developing the treatment plan with the client and obtaining the client's signature as evidence of this collaboration. The Quality Improvement Department will ensure ongoing compliance via random chart reviews. |