INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 2-3, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Progressive Medical Specialist, 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 inspection and a plan of correction is due on September 3, 2010.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records on August 2, 2010 and an interview with the project/facility director on August 3, 2010, the clinical supervisor failed to complete a core curriculum training in clinical supervision.
The findings include:
Five personnel records were reviewed on August 2, 2010. One personnel record reviewed was required to include documentation of a core curriculum training in clinical supervision. Per regulation, clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. The facility did not document the completion of a core curriculum training in clinical supervision in personnel record # 2.
Employee # 2 was hired by the facility on June 27, 2005 and promoted to clinical supervisor on August 3, 2009. As of the date of the personnel record review on August 2, 2010, personnel record #2 did not include documentation of the completion of a core curriculum training in clinical supervision.
An interview with the project/facility director on August 3, 2010 confirmed employee #2 had not completed a core curriculum training in clinical supervision and was not scheduled to attend a core curriculum training in clinical supervision.
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Plan of Correction
As discussed during the inspection visit, we attempted to enroll our clinical supervisor in the most recent clinical supervision training offered by BDAP and the class was full.
Also, this class is not offered very often and it is difficult to be enrolled due to alloted space for each class.
We, (clinical supervisor) will monitor the BDAP web site on a weekly basis to look for announcemnets of the clinical supervision core curriculm training, in an attempt to be one of the first agencies to obtain the information and enroll in the program.
We have contacted BDAP on August 6, 2010 and asked to be contacted via email to when the next class in being offered and to let them know that we have one staff member who is in need of this training.
We will make every attempt to enroll the clinical supervisor in this required training as soon as we are able to enroll in an offered class. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection and an interview with the project/ facility director, the facility failed to ventilate the patient bathrooms by an exhaust fan or window.
The findings include:
A physical plant inspection was conducted with the project/ facility director on August 3, 2010 from approximately 2 PM until 2:15 PM. Per regulation, the nonresidential facility shall ventilate bathrooms by exhaust fan or window. The facility has one single occupancy patient men's bathroom and one single occupancy patient women's bathroom. The bathrooms do not have any windows. There were exhaust fans in the bathrooms which were not operational.
The project/facility director confirmed on August 3, 2010, that the exhaust fans in the bathrooms were not operational .
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Plan of Correction
On August 5, 2010 the exhaust fans in the male and female client bathrooms were fixed and operational by maintenance staff used by Progressive Medical |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of patient records and an interview with the project/facility director, the facility failed to document an aftercare plan in one of three patient records.
The findings include:
Twenty patient records were reviewed on April 7, 2009. An aftercare plan was required in three patient records. The facility did not document an aftercare plan in patient record # 19.
In patient record # 19, the patient was admitted on August 6, 2009 and was successfully discharged on March 5, 2010. There was no documentation of an aftercare plan.
An interview with the project/facility director on August 3, 2010, confirmed there was no documentation of an aftercare plan in patient record #19.
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Plan of Correction
All clinical staff met with clinical supervisor and reviewed the procedure of completing an aftercare plan on August 4, 2010.
It was decided that the clinical superviosr will review each discharge chart within a 5 day period after the client is discharged to ensure that required paperwork is completed, which includes an aftercare plan, (if required)
The primary counselor of client # 19 was aware that a aftercare plan should have been completed, we believe it was an oversite of the counselor. |