INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 7, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services 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 and a plan of correction is due on
March 8, 2011.
|
Plan of Correction
|
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
|
Observations
Based on the review of employee personnel, administrative documentation, and an interview with the Vice President of Quality Improvement, the facility failed to document monthly supervisory sessions for each new supervisor for the first six months of employment.
The findings include:
On January 31, 2011 and February 1, 2011 personnel records were reviewed. The "Staffing Requirements Facility Summary Reports" was reviewed. Employee record # 3 was listed as the clinical supervisor with the start date of 5/24/2010. The record did not have any documentation of supervisory notes for the initial six months of employment for employee #3. An interview with the Vice President of Quality Improvement on January 31, 2011 at 12:55 p.m. confirmed that the clinical supervisor did not have documented monthly supervisory meetings with their supervisor for the first six months of employment in that position.
|
Plan of Correction
Pennsylvania Counseling Services submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State laws relating to drug and alcohol treatment. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or an admission of past or ongoing violations of applicable regulatory requirements.
The Vice President of Quality Improvement and Director of Quality Improvement will ensure that the clinical supervisor receives monthly supervision with his/her supervisor to discuss his/her duties and performance. The monthly supervision meetings will occur for 6 months starting March 2011 and frequency of meetings thereafter will be based upon the clinical supervisor's skill level. Documentation of these meetings will be kept in the personnel file.
|
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
|
Observations
Based on the review of client records, the facility failed to give the client an opportunity to request reconsideration of a decision terminating treatment.
The findings include:
Seven client records were reviewed on February 7, 2011. The project was required to give the client an opportunity to request reconsideration of a decision terminating treatment in one client record. The project did not document that the client was given an opportunity to request reconsideration in client record # 5.
An interview with the Vice President of Quality Improvement and the Director of Quality Improvement confirmed that the letter in the client record did not give the client the opportunity to request consideration of the decision of termination.
|
Plan of Correction
The Vice President of Quality Improvement and Director of Quality Improvement will ensure that all staff are re-educated through staff meeting to utilize our formatted discharge notification form which gives the client an opportunity to request reconsideration of a decision to terminate treatment. The local office administration and Quality Improvement department will monitor ongoing compliance via random record reviews. |