INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 20, 2015, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Al-Assist Behavioral Health Care Center 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(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 a review of the personnel and training records, the facility failed to document that a core curriculum in clinical supervision was completed in one of one record.The findings include: Five personnel and training records were reviewed on July 20, 2015. The facility was required to document that a core curriculum in clinical supervision was completed in record, #1. Employee #3 was hired on 8/11/2014 as a Clinical Supervisor. No documentation was available to show that the employee functioned for 2 years as a supervisor in the provision of clinical services or that they completed the required core curriculum in clinical supervision. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Standard in Non-Compliance
704.6(c) LICENSURE
Core Curriculum - Supervisor Training:
In an effort to address the non-compliance of standard 704.6 (c), the clinical supervisor identified as non-compliant to standard 704.6 (c) has been assigned to complete prior to August 21, 2015, the following course work offered by Lybans Addiction Specific Trainings: Clinical Supervision Principles - Clinical Foundations and Clinical Supervision Principles Techniques & Methods. In addition, the staff person will be registered to participate in the Clinical Supervisor Training soon to be scheduled for December 2015.
To avoid any future Non-Compliance for Standard 704.6 (c), any potential supervisor with less than 2 years experience will be required to complete a core curriculum in clinical supervision during orientation and prior to providing direct supervision. In addition, newly hired supervisors will be required to attend and successfully complete CST.
This Process will be enforced by the Coordinator of Behavioral Healthcare Services
This Process will be Monitored by the Quality Assurance and Credentialing Department.
Correction Time: December 30, 2015
Monitoring On Going |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on an observation and a physical plant inspection, the facility failed to provide an operable soap dispenser in two of four facility bathrooms. The findings include:A physical plant inspection was completed on July 20, 2015. During the physical plant inspection it was observed by this licensing specialist that two of the bathrooms located on the 2nd floor of the facility failed to have an operable soap dispenser for staff and clients. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Standard in Non-Compliance
705.6 (2) Licensure
Bathrooms
In an effort to address the non-compliance of standard 705.6 (2), wall mountable soap dispensers with locks have been ordered to replace the hand held soap dispensers. The non-portable soap dispensers will be installed immediately upon delivery.
Correction Time 8/14/2015
Monitoring: Cleaning Company & Security officers.
Random audits will be conducted by the QA Department to ensure compliance.
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