INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7, 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, Project Transition 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 facility 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 for the 6 facilities contained within the project were reviewed on August 6, 2015. The equivalent of 17 full-time counselors are employed within the project. This would require at least 2 full-time clinical supervisors. The project currently employs 1 full-time clinical supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
These findings were reviewed with the Project Director. Based on the review of these findings and a review of our staffing model against DDAP Regulations, we have designated 2 additional full-time Clinical Supervisor positions. These will be full time positions, will not carry any direct case loads and will provide the direct supervision over the counselors. The Project Director filled both positions by 9/1/15 with two individuals who are Certified Addictions Counselors with extensive clinical and supervisory experience. To prevent this issue from occurring in the future, the project director will monitor the formula for calculating how many FTE counselors are in the project and the project director will ensure that the project employs the required number of clinical supervisors based on the results of these calculations. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill logs and a conversation with the project director, the facility failed to conduct an unannounced fire drill at least once a month.
The findings include:
A review of the July 2014 through July 2015 fire drill logs was conducted on August 7, 2015. During the month of August 2014, the facility failed to conduct an unannounced fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The findings were reviewed with the Project Director. The Project Director will review the Fire Safety Policies with the Facility Director to confirm an understanding of the monthly fire drill requirement. Additionally Project Transition will institute a new process that includes a drill completion by date prior to the end of each month. This will allow a monthly review of completed drill with time allowed for corrective action within the monthly time frame if a drill has not been been completed. The Project Director is responsible for oversight of the new process and will work with the Facility Director to ensure all drills are completed as required. If drills are not completed on time, the Facility Director will be subject to disciplinary action. |