INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 20, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Genesis House - Harrisburg 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(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 the Staffing Requirements Facility Summary Reports, the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The Staffing Requirements Facility Summary Reports was reviewed on December 27, 2014 and re-reviewed at the time of the inspection. There are 3 different facilities contained within the project. The equivalent of 14.95 full-time counselors is employed within the project. This would require at least 1 full-time clinical supervisor. The project currently has 3 clinical supervisors with 1 clinical supervisor at each facility in the project; however, all 3 clinical supervisors maintain a client caseload of 15 or more and devote only 20 hours per week towards clinical supervision. Therefore, the project currently does not employ one full-time clinical supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Board of Directors met and reviewed the DOH citations on 1/30/15. The Board of Directors and the Project Director will identify 1 full-time Clinical Director by 2/28/15 and transition the Clinical Director from their current job duties to their new job duties by 3/15/15. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to have heaters that are permanently mounted or installed in two offices.
The findings include:
The physical plant inspection took place on January 20, 2015 at 4:00 pm. There were space heaters found in office closets of the facility director and counselor office #3. The two heaters were not permanently mounted or installed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The heating/cooling system will have an additional temp until installed in the group room to allow for proper circulation of heat. This will be completed by the maintenance team by 3/1/15.
The clinical director will inspect all offices including drawers and closets once a week to ensure no violations of policy exist. All violations will be reported to the project director immediately. |