D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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STAIRWAYS BEHAVIORAL HEALTH OUTPATIENT DRUG AND ALCOHOL PROG
2911-19 STATE STREET
ERIE, PA 16508

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Survey conducted on 07/09/2015

INITIAL COMMENTS
This report is a result of a supervisory review of the written report of the findings of an on-site licensing inspection that was conducted on February 19, 2015 by staff from the Program Licensure Division. Based on the supervisory review of findings from the on-site inspection, Stairways Behavioral Health Outpatient Drug and Alcohol Program was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiency was identified during this supervisory review:	Plan of Correction
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.
Observations Based on a review of the "Staffing Requirements Facility Summary Reports" (SRFSR), 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: The SRFSR lists a total of ten full-time counselors and two clinical supervisors. The total of the hours per week provided to the project by counselors equates to ten (FTE)counselor positions within the project. The SRFSR revealed that no employees were listed as a full-time clinical supervisor. The SRFSR listed one of the two clinical supervisors as facility director; therefore they were unable to provide full-time clinical supervision. In addition one of the two clinical supervisors was listed as working only five hours per week, therefore they were unable to provide full-time clinical supervision.	Plan of Correction The clinical supervisor was providing clinical supervision between two programs at the time of inspection and his time was documented incorrectly on the staffing form. As of 4/6/15, the clinical supervisor returned full time to this facility. The proper clinical supervisor/staff ratio will continue to be followed.