INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 18 - 19, 2011 and January 20 - 21, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, SPHS Behavioral Health 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 February 22, 2011.
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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 staffing requirements facility summary reports and an interview with the facility director, the project failed to provide a full-time clinical supervisor for every eight full-time counselors and counselor assistants.
The findings include:
Six staffing requirements facility summary reports were reviewed on January 18 - 21, 2011. The project consists of six facilities. These six facilities are managed by one facility director. Per regulation, a drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both. As of January 21, 2011, the project has 29.35 full-time counselors and only two full-time clinical supervisors. Three full-time clinical supervisors would be required for 29.35 full-time counselors.
The facility director was interviewed throughout the inspection process from January 18 - 21, 2011. The facility director confirmed that there are only two full-time clinical supervisors for the project.
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Plan of Correction
Project Director and Facility Director will transfer 1 Supervisor to Full-Time Drug and Alcohol Clinical Supervisor position to provide 3 Full-Time Drug and Alcohol Clinical Supervisors for the project to meet this regulation.
It shall be the responsibility of the Project Director and Facility Director to insure there is 1 Full-Time Drug and Alcohol Clinical Supervisor for every 8 Full-Time Equivalent Counselors and Counselor Assistants for this project. It shall also be the responsibility of the Project Director and Facility Director to insure these Full-Time Drug and Alcohol Supervisors have no other duties assigned and ongoing compliance with these regulations through quarterly staffing pattern reviews.
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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
Based on a review of personnel records and an interview with the facility director, the facility failed to document HIV/AIDS and TB/STD training in one of two personnel records.
The findings include:
Ten personnel records were reviewed on January 19, 2011. Two personnel records were reviewed for documentation of HIV/AIDS and TB/STD training. Per regulation, 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. The facility failed to document HIV/AIDS and TB/STD training in employee record # 10.
Employee # 10 is support staff and was hired on February 6, 2004. HIV/AIDS and TB/STD training were due to be completed no later than February 6, 2006. Verification of HIV/AIDS and TB/STD training was not available for review at the time of the licensing inspection on January 19 - 21, 2011.
The facility director was interviewed on January 20 - 21, 2011 and confirmed that employee # 10 had been scheduled for training but had not completed HIV/AIDS or TB/STD training.
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Plan of Correction
Employee #10 will be scheduled for HIV/AIDS and TB/STD/Communicable Disease training at the next available training date.
It shall be the responsibility of the Clinical Supervisor to insure all clinical staff are trained on HIV/AIDS and TB/STD/Communicable Disease within the first year of employment and non-clinical staff within their first 2 years of employment. It shall be the responsibility of the Clinical Supervisor to insure ongoing compliance with this regulation through quarterly reviews of staff training plans. |