Graff, TinaThis 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 February 18, 2015, by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from the on-site inspection, Crossroads Counseling 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 supervisory review:
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Plan of Correction
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Observations
Based on a review of the "Staffing Requirements Facility Summary Reports" (SRFSR) for all of the facilities in the Project, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the Project.The findings include:A review of the SRFSR was conducted on May 15, 2015. The SRFSR for the four facilities that make up the project list a total of 25 counselors, 3 counselor assistants, and 4 clinical supervisors. The total of the hours per week provided to the project by counselors equates to 27.425 FTE counselor positions within the project, thus, requiring 3 full time clinical supervisors.The SRFSR for the four facilities within the project listed four employees as clinical supervisors, two as full time clinical supervisors and two that also served in the capacity of clinicians. Therefore, two of the clinical supervisors were unable to provide full-time clinical supervision.
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Plan of Correction
Executive Director will complete the facility staffing form and properly document the number of clinical hours under the correct headings. ED now understands that when completing the clinical staffing form that clinical supervisor time is to be assigned to the "other" category rather than being assigned to "drug and alcohol." The executive director will be also responsible for completion and review of the Staffing Requirements Facility Summary Report prior to pre-submission and be responsible to ensure that the agency always meets the requirements of 704.6(a). We currently have 4 full time clinical supervisors. |