INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 15-16, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alliance Medical 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:
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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 project ' s Staffing Requirements Facility Summary Reports (SRFSR), 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 3 facilities contained within the project were reviewed on July 7-8, 2014. Based on documentation contained within the SRFSRs the project employed the equivalent of 34.25 full-time counselors. This would require at least 4 full-time clinical supervisors. At the time of inspection, the project only employed 2 full-time clinical supervisors.
The findings were discussed and confirmed with facility staff and were not disputed.
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Plan of Correction
Pinnacle Treatment Centers will comply with regulation 704.6 and will employ Clinical Supervisors to meet the ratio for the entire project. In doing so, Ensign I recently hired a new Clinical Supervisor and an additional Clinical Supervisor position was posted. These positions will enable the project to employ four Clinical Supervisors. In addition, Lead Counselors in both Ensign I and Johnstown will supplement the staffing plan. All positions will be in place by 10/1/14.
Regional Directors along with Facility Directors will ensure compliance with this regulation moving forward so that the entire project is staffed appropriately in the future.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all heaters were permanently mounted or installed.
The findings include:
A physical plant inspection was conducted on July 16, 2014. During the inspection two space heaters were observed in a locked closet and one space heater was observed in a counseling office.
The facility director confirmed the findings.
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Plan of Correction
All space heaters were removed from the facility by Facility Director as of 8/1/14. The Health and Safety Committee will check all offices monthly during building inspections to ensure that no heaters are present in offices or storage areas. Staff will all be reminded of this regulation via staff meeting by 8/19/14. |