INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 14, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services York Psychiatric 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 18, 2011.
|
Plan of Correction
|
705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
|
Observations
Based on observation during an inspection of the facility's physical plant, the facility failed to ensure the facility provided an operable soap dispenser in each bathroom.
The findings include:
On February 14, 2011, a physical plant inspection was conducted between 2:15 PM and 2:41 PM. The Facility Director and the Director of Quality Improvement accompanied the Licensing Specialists during the physical plant inspection. It was observed that the wall mounted soap dispenser was missing from the client bathroom on the second floor.
This was confirmed by the Director and the Director of Quality Improvement.
|
Plan of Correction
A new soap dispenser has been installed in the client bathroom on the second floor. The Vice President of Quality Improvement, Director of Quality Improvement, and local office administration will ensure that there is always an operable soap dispenser in each bathroom. |
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 personnel records, the "Staffing Requirements Facility Summary Report " completed by the facility 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 Report" was reviewed. Employee record # 2 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 #2. 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.
|