INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 2, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Project Transition 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
The Staffing Requirements Facility Summary Reports for the 5 facilities were reviewed on August 2, 2016. Based on this review, the facility failed to have a full-time clinical supervisor for every eight full-time counselors and/or counselor assistants.
The equivalent of 8 full-time counselors were employed within the project requiring at least 1 full-time clinical supervisor. The project did not have a full-time clinical supervisor employed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
These findings were shared with the facility on 11/4/16 and reviewed with the Project Director. Based on the review of these findings and a review of our staffing model against DDAP Regulations, we have designated 1 full-time Clinical Supervisor positions filled by Dr. Terry Murphy. These will be full time position, will not carry any direct case loads and will provide the direct supervision over the counselors. To prevent this issue from occurring in the future, the project director will monitor the formula for calculating how many FTE counselors are in the project and the project director will ensure that the project employs the required number of clinical supervisors based on the results of these calculations. |
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
Personnel records were reviewed on August 2, 2016. Based on this review, the facility failed to document STD/TB and other health related topics training in personnel record #5.
The findings include:
Employee #5 was hired as a residential advisor on October 8, 2013 and STD/TB and other health related topic was due to be completed no later that October 9, 2015. Documentation of this training was not available at the time of this inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
These findings were shared with the facility on 11/4/16 and reviewed with the Project Director. Based on the review of these findings and a review of our current training plan it was determine that a four hour TB/STD training was made available to Project Transition Staff once per quarter. Staff #5 neglected to register for TB/STD in house training and community offered trainings. Employee # 5 is no longer employed with Project Transition. To prevent future non-compliance with required TB/STD training within the first year of employment, employees are required to participate in the TB/STD trainings or they will receive disciplinary actions for both staff member and direct supervisor with the expectations of training completion within 30 days of the written notice. |