INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 2, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, John F. Kennedy Behavioral Health Center, was found to be not 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
The facility failed to document that all clinical supervisors had the required supervisory experience or received the core curriculum in clinical supervision.Employee #3 was hired as a clinical supervisor on 3/23/16 but did not have the required 2 years of supervising others at the time of hire. #3 has not completed the a DDAP approved core curriculum in clinical supervision.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Employee #3 was hired on 3/23/16 and had completed the two years of supervising others at the time of licensing visit on 10/2/18.
the agency will ensure that in the future when a clinical supervisor is hired, the individual has the two years of supervising others prior to the date of hire. Person responsible is director of HR. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
The facility failed to document a valid consent to release information for clients #1-9. The facility consent template states that the consent may only be revoked by notifying the therapist, case manager or doctor. Client #1 was admitted on 8/24/18 and was an active client at the time of the licensing inspection. Client #2 was admitted on 8/22/18 and was an active client at the time of the licensing inspection. Client #3 was admitted on 1/3/18 and was an active client at the time of the licensing inspection. Client #4 was admitted on 7/12/18 and was an active client at the time of the licensing inspection.Client #5 was admitted on 11/27/17 and was discharged on 6/19/18.Client #6 was admitted on 2/12/18 and was discharged on 4/16/18.Client #7 was admitted on 3/2/18 and was discharged on 6/26/18.Client #8 was admitted on 4/5/18 and was discharged on 9/7/18.Client #9 was admitted on 6/28/18 and was discharged on 9/14/18.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
the consent template was revised immediately to state that the consent may be revoked "at any time by written or verbal request".
Effective nov.15, 2018 all new and existing clients will sign the revised consent form reflecting the change stated above |