INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9-10, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alliance Medical Services 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
Based on a review of the Staffing Requirements Facility Summary Reports, the facility failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.The findings include:The Staffing Requirements Facility Summary Reports for the 3 facilities contained within the project were reviewed on July 7-8, 2014. The equivalent of 34.25 full-time counselors are employed within the project. This would require at least 4 full-time clinical supervisors. The project currently employs 2 full-time clinical supervisors.The findings were discussed and confirmed with facility staff and were not disputed.
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Plan of Correction
Pinnacle Treatment Centers will comply with regulation 704.6 and will employ Clinical Supervisors to meet the ratio for the entire project. In doing so, Ensign I recently hired a new Clinical Supervisor and an additional Clinical Supervisor position was posted. These positions will enable the project to employ four Clinical Supervisors. In addition, Lead Counselors in both Ensign I and Johnstown will supplement the staffing plan. All positions will be in place by 10/1/14.
Regional Directors along with Facility Directors will ensure compliance with this regulation moving forward so that the entire project is staffed appropriately in the future.
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709.26(d)(3) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(3) The verification of training experience and professional licensure or registration, where applicable.
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Observations
Based on a review of personnel records, the facility failed to document verification of training experience and professional licensure or registration, where applicable.The findings include:Four personnel records were reviewed on July 9-10, 2014. One of the personnel records reviewed was for the facility director. The facility director, personnel record #2, was hired on May 5, 2014. The facility director's personnel record did not include any documentation of a degree certificate or college transcripts.The findings were discussed and confirmed with the clinical supervisor and facility director and were not disputed.
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Plan of Correction
It is the responsibility of the facility to assure that all personnel records are complete to satisfy all regulations set forth in 709.26.
In this case, the facility director was hired on 5/5/2014 and his onsite personnel file did not contain documentation of degree certificate or college transcripts.
The deficient documentation was requested and will be received by 8/31/14 at which time it will be placed in the employee onsite personnel file.
The PTC Human Resources Director and Facility Director are responsible to provide the necessary oversight to insure that all personnel records meet and conform to the regulations set forth in 709.26.
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