This report is a result of a supervisory review of the written report of the findings of an on-site licensure inspection that was conducted on March 1, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the supervisory review of findings from the on-site inspection, Clinical Outcomes Group Incorporated, 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 supervisory review:
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Plan of Correction
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Observations
Based on a supervisory review of the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the clinical staff FTE equated to 8.9 full time equivalent clinical staff. The FTE calculation for the amount of clinical supervisors needed is as follows:
The total # of hours project-wide devoted to D&A clients divided by the project ' s standard workweek, or 356 hours / 40 hours = 8.9 FTE
The project must have a full time clinical supervisor on staff for every 8 FTE clinical staff and based on the SRFSR, the facility does not employ a full time clinical supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will review candidate for the full time Clinical Supervisor with our Board of Directors at our March 22, 2017 meeting. Once the position is approved the lead counselor will be promoted to Clinical Supervisor on March 23, 2017. Lead Counselor meets the criteria for Clinical Supervisor. Counselor will begin Clinical Supervisor training in April 2017. Agency will be in compliance with a full time supervisor by March 23, 2017. |