INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11-12, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Progressive Medical Specialists, Inc. 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 personnel records on July 11, 2011 and an interview with the project/facility director on July 12, 2011, the clinical supervisor failed to complete a core curriculum training in clinical supervision.
The findings include:
Seven personnel records were reviewed on July 11, 2011. One personnel record reviewed was required to include documentation of a core curriculum training in clinical supervision. Per regulation, 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. The facility did not document the completion of a core curriculum training in clinical supervision in personnel record # 2.
Employee # 2 was hired by the facility on June 27, 2005 and promoted to clinical supervisor on August 3, 2009. As of the date of the personnel record review on July 11, 2011, personnel record #2 did not include documentation of the completion of a core curriculum training in clinical supervision.
An interview with the project/facility director on July 12, 2011 confirmed employee #2 had not completed a core curriculum training in clinical supervision and was not scheduled to attend a core curriculum training in clinical supervision.
This is a repeat non-compliance from the previous survey.
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Plan of Correction
During the interview with state inspector it was discussed that prior clinical supervisor had not had current clinical supervisor sign a lead counselor job description when she began supervising counselor and counselor assistants and completing chart reviews in 2005.
Since current clinical supervisor had worked with us from March 7, 2002 as a counselor assistant, obtained full counselor status on August 15, 2003, resigned from her counselor position on January 2, 2004. (Staff member resigned to complete her practicum for her master of education degree). She then returned to work with us on June 27, 2005 with full counselor status as per state guidelines and was promoted to a lead counselor position on October 10, 2005 as determined by her 90 day review and salary increase. Unfortunately her personnel documentation does not reflect her prior supervision experience and training. Since project director has used the lead counselor job descriptions at the Houston, PA location and has always promoted from within the company, (counselor to lead counselor to clinical supervisor) policy and procedure have been created and used to ensure that the supervision requirement has been met in the past it can only be deduced that prior clinical supervisor did not follow procedure with documenting this staff member's supervisor experience. If it had been documented this outside training would never had been needed nor would we have been cited for this standard in the past.
This staff member had met the required supervision time to be promoted to a clinical supervisor. But due to personnel documentation and prior supervisor failing to have a signed lead counselor job description we are required to obtain state approved clinical supervisor training.
We have attempted to enroll in the one training offered since last inspection but do to schedule conflict of current clinical supervisor and travel distance we were unable to enroll her in this training.
We are actively seeking a state approved clinical supervisor training using the BDAP web site as well as looking into the possibility of a training being offered at the October 2011 conference at Seven Springs. (As of July 19, 2011 the BDAP web site is not showing any clinical supervision trainings scheduled).
We will request enrollment at the next clinical supervision training offered to fulfill this requirement.
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative policies and procedures and an interview with the Project Director, the facility failed to complete an annual audit of financial activities for the January 1, 2010 through December 31, 2010 fiscal year.
The findings include:
A review of administrative policies and procedures, and an interview with the Project Director was conducted on July 11, 2011. Per regulation, the project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services. The project's fiscal year is from January through December. The project's annual audit of financial activities for January 1, 2010 through December 31, 2010 was not completed as of July 12, 2011. The project failed to document the completion of an annual audit for the 2010 fiscal year.
On July 11, 2011, the project director confirmed the 2010 audit had not been completed.
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Plan of Correction
Prior to January 2011 the type of financial audit we had completed was accepted due to our S-corp status. Since the change with the State of Pa January-February 2011 licensing alert we have had to request a different type of financial audit from our accountant.
As a result, director contacted Josh Estner of Milton Estner Accounting firm on July 14, 2011, (after obtaining board approval) and requested that the 2011 financial audit of Progressive Medical Specialists, Inc be completed as a full annual audit as per state licensing regulations.
Our fiscal calendar runs January thru December 2011 as a result, the report will be completed and submitted to the board by the end of February 2012 and will be available for state review at next licensing visit.
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