INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 24, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Service 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.
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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 " Staffing Requirements Facility Summary Reports " for all of the facilities in the Project and interviews with the Project ' s administrative staff, 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 " Staffing Requirements Facility Summary Reports " for the nine facilities that make up the project list a total of 59 counselors and/or counselor assistants who are fee-for-service employees and/or full- or part-time employees. The total of the hours per week provided to the project by counselors and/or counselor assistants equates to 30.69 FTE counselor and/or counselor assistant positions within the project.
The " Staffing Requirements Facility Summary Reports " for each of the nine facilities within the project revealed that no employees were listed as full-time clinical supervisors. A full-time equivalency of 30.69 counselors and/or counselor assistants requires a minimum of 3 full-time clinical supervisors within the project.
The Executive Director is listed as the Project Director (designated as employee # 1 for facility number 367070) and as the Facility Director for facility numbers 227059, 387012, and 677044 and cannot also act as a full-time clinical supervisor. The person listed as the Facility Director for facility numbers 067079, 217049, 017068, 367070 and 067058 (designated as employee # 2 for facility number 367070) cannot also act as a full-time clinical supervisor. The person listed as the Facility Director and clinical supervisor for facility number 387019 (designated as employee # 2 for facility number 387019) cannot also act as a full-time clinical supervisor.
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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 there is one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors and/or counselor assistants in the entire Project. The Vice President of Quality Improvement and Director of Quality Improvement will ensure that these supervisors meet DOH staffing regulations for the position of full-time Clinical Supervisor. The Vice President of Quality Improvement and Director of Quality Improvement will also ensure that the Staffing Requirement Facility Summary Reports are completed accurately to reflect these supervisory hours for future inspections.
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709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on the physical plant inspection, the facility failed secure client records within locked storage containers.
The findings include:
The physical plant inspection took place on February 24, 2010 at around 9:20am. The discharge records were stored in a locked storage room, but were not secured in locked storage containers. The storage room was also used for storage of toys and cleaning materials. The Director of Quality Improvement was interviewed and she informed me that the holiday items and cleaning materials will be removed. They are also thinking about making a separate room for the discharge records within the existing storage room.
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Plan of Correction
The PCS Maintenance Department will construct a separate locked room within the basement of our York Facility to store only the discharge records. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to completely document psychosocial evaluations in nine of nine records reviewed.
The finding includes:
Nine records were reviewed on February 24, 2010. Psychosocial evaluations were required in nine records reviewed.
Client record #1 failed to document the client ' s problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, clients attitude towards treatment and the counselor conclusions/impressions.
Client record #2 failed to document the client ' s problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, clients attitude towards treatment and the counselor conclusions/impressions.
Client record #3 failed to document the client ' s problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, clients attitude towards treatment and the counselor conclusions/impressions.
Client ' s records #4 failed to document the client ' s assets/strengths, support systems, negative factors that might inhibit treatment and the counselor conclusions/impressions.
Client record #5 failed to document the client ' s assets/strengths, support systems and the counselor conclusions/impressions.
Client ' s records #6 failed to document the client ' s assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, clients attitude towards treatment and the counselor conclusions/impressions.
Client ' s records #7 failed to document the client ' s problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions.
Client ' s records #8 failed to document the client ' s assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions.
Client ' s records #9 failed to document the client ' s problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, clients attitude towards treatment and the counselor conclusions/impressions.
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Plan of Correction
The Director of Quality Improvement met with and re-educated staff on 2/24/10 in regards to the content of the Psychosocial Evaluation. The QI Department will ensure ongoing compliance via random chart reviews. |