INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 14, 2009 through December 15, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Parkside Recovery 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 January 15, 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 the review of personnel records, the facility failed to ensure that a clinical supervisor who did not have two years of clinical supervisory experience completed a core curriculum in clinical supervision. The facility failed to ensure that the training was obtained for three of three clinical supervisors where required.
The finding includes:
Twenty-seven personnel records were reviewed on December 14, 2009 through December 15, 2009. Documentation of core curriculum training in clinical supervision was required in three of six clinical supervisors' personnel records.
Employee #15 was hired on September 24, 2007 and was promoted to clinical supervisor on 10/27/08. This employee did not have the required two years clinical supervisory experience prior to the promotion. As of December 15, 2009, there was no documentation of the core curriculum training in personnel record #15.
Employee #17 was hired on October 28, 2002 and was promoted to clinical supervisor on August 2008. This employee did not have the required two years clinical supervisory experience prior to the promotion. As of December 1, 2009, there was no documentation of the core curriculum training in personnel record #17.
Employee #20 was hired on September 9, 2002 and was promoted to clinical supervisor on October 27, 2008. This employee did not have the required two years clinical supervisory experience prior to the promotion. As of December 1, 2009, there was no documentation of the core curriculum training in personnel record # 20.
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Plan of Correction
The Program Director will ensure that the clinical supervisors who do not have two years of clinical supervisory experience complete the core curriculum in supervision as required. We are registering our clinical supervisors who need the clinical supervisors training. The date of the training is March 8 through 12th in Philadelphia.
Time Frame: Immediately training March 8 through March 12th.
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on the review of personnel records, the facility failed to document the assessment of staff training needs within the time frames listed in facility policy and procedure in eleven of twenty-seven employee records reviewed.
The finding includes:
Twenty-seven personnel records were reviewed on December 14, 2009 through December 15, 2009. Assessment of staff training needs was required in twenty-seven personnel records reviewed. Per the facilities policy and procedures; policy number 740.005; reviewed on December 14, 2009 & December 15, 2009, the individualized assessments of staff training needs are to be completed prior to the beginning of the current training year.
The facility's training year begins on July 1 of each year and ends June 30 of the following year.
Employee #1 was hired on 5/20/03 and promoted to the current position of clinical supervisor on 6/7/07. The facility's training year is from July 1, 2009 to June 30, 2010. The assessment of staff training needs for this employee was not completed until October 2009.
Employee #9 was hired on 8/10/02. The facility's training year is from July 1, 2009 to June 30, 2010. The assessment of staff training needs was not completed until October 18, 2009.
Employee #11 was hired on 9/5/06. The facility's training year is from July 1, 2009 to June 30, 2010. The assessment of staff training needs was not completed until August 8, 2009.
Employee #12 was hired on 3/31/08. The facility's training year is from July 1, 2009 to June 30, 2010. The assessment of staff training needs was not completed until December 19, 2009.
Employee #13 was hired on 4/13/09. The facility's training year is from July 1, 2009 to June 30, 2010. The assessment of staff training needs was not completed until October 22, 2009.
Employee #14 was hired on 10/9/06. The facility's training year is from July 1, 2009 to June 30, 2010. The assessment of staff training needs was not completed until November 30, 2009.
Employee #19 was hired on 12/6/04 and promoted to the current position of Project Director on 3/31/08. The facility's training year is from July 1, 2009 to June 30, 2010. The assessment of staff training needs was not completed until July 23, 2009.
Employee #20 was hired on 9/9/02 and promoted to the current position of clinical supervisor on 10/27/08. The facility's training year is from July 1, 2009 to June 30, 2010. The assessment of staff training needs was not completed until December 14, 2009.
Employee #24 was hired on 1/12/09. The facility's training year is from July 1, 2009 to June 30, 2010. The assessment of staff training needs was not completed until October 16, 2009.
Employee #27 was hired on 3/24/03 and promoted to the current position of clinical supervisor on 2/1/06. The facility's training year is from July 1, 2009 to June 30, 2010. The assessment of staff training needs was not completed until October 9, 2009.
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Plan of Correction
The program director will schedule all assessments of training needs for staff at the beginning of the month before the end of the fiscal year; May of each fiscal year.
Completed: Immediately |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of personnel records, the facility failed to document individual training plans within the time frames listed in facility policy and procedure in ten of twenty-seven client records reviewed.
The finding includes:
Twenty-seven personnel records were reviewed on December 14, 2009 through December 15, 2009. Individual training plans was required in twenty-seven personnel records. Per the facility's policy and procedures; policy number 740.005; reviewed on December 14, 2009 & December 15, 2009, individual training plans are to be completed at the end of the facility's training year after the assessment of staff training needs. An interview was conducted with the Assistant Program Director on December 16, 2009. The Assistant Program Director confirmed that the individual training plans are to be done by the end of the facility's training year once the assessment of staff training needs has been completed. The facility's training year begins on July 1 of each year and ends June 30 of each year.
Employee #1 was hired on 5.20/03 and promoted to the current position of clinical supervisor on 6/7/07. The facility's training year is from July 1, 2009 to June 30, 2010. The individual training plan for this employee was not completed until July 20, 2009.
Employee #2 was hired on 3/30/09. The facility's training year is from July 1, 2009 to June 30, 2010. The individual training plan for this employee was not completed until June 1, 2009. Employee #2 was hired on March 30, 2009, but the facility failed to document a training plan for the remainder of the July 1, 2008 to June 30, 2009 training year.
Employee #4 was hired on 3/16/09. The facility's training year is from July 1, 2009 to June 30, 2010. The individual training plan for this employee was not completed until June 1, 2009. Employee #4 was hired on March 16, 2009, but the facility failed to document a training plan for the remainder of the July 1, 2008 to June 30, 2009 training year.
Employee #9 was hired on 8/10/02. The facility's training year is from July 1, 2009 to June 30, 2010. The individual training plan was not completed until September 30, 2009.
Employee #12 was hired on 3/31/08. The facility's training year is from July 1, 2009 to June 30, 2010. The individual training plan was not completed until July 20, 2009.
Employee #13 was hired on 4/13/09. The facility's training year is from July 1, 2009 to June 30, 2010. The individual training plan was not completed until July 23, 2009.
Employee #14 was hired on 10/9/06. The facility's training year is from July 1, 2009 to June 30, 2010. The individual training plan was not completed until November 30, 2009.
Employee #17 was hired on 10/28/02 and promoted to clinical supervisor on 8/1/06. The facility's training year is from July 1, 2009 to June 30, 2010. The individual training plan was not completed until October 5, 2009.
Employee #19 was hired on 12/6/04 and was promoted to Project Director on 3/31/08. The facility's training year is from July 1, 2009 to June 30, 2010. The individual training plan was not completed until July 15, 2009.
Employee #24 was hired on 1/12/09. The facility's training year is from July 1, 2009 to June 30, 2010. The individual training plan was not completed for the 2009 - 2010 training year until October 12, 2009. The facility failed to document a training plan for the remainder of the July 1, 2008 to June 30, 2009 training year.
Employee #25 was hired on 3/30/09. The facility's training year is from July 1, 2009 to June 30, 2010. The individual training plan was not completed for the 2009 - 2010 training year until June 1, 2009. The facility failed to document a training plan for the remainder of the July 1, 2008 to June 30, 2009 training year.
Employee #27 was hired on 3/24/03. The facility's training year is from July 1, 2009 to June 30, 2010. The individual training plan was not completed for the 2009 - 2010 training year until July 20, 2009.
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Plan of Correction
The program director will schedule during mid May through the end of May of each fiscal year, for all staff training plans to completed according to the previous completed training needs assessments.
Completed: Immediately |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection, the facility failed to ensure that portable heaters were not allowed in the facility.
The finding includes:
The physical plant tour took place on December 17, 2009 at around 10:15 am. During the physical plant inspection a portable heater was found around 10:35 AM in a therapist's office on the second floor. An interview with the Security Supervisor was conducted on December 17, 2009, at which time the licensing specialists were informed that the facility did not know that the portable heater was in the therapist's office.
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Plan of Correction
Staff has been notified that they must not have any space heaters in the facility. The space heater that was found was removed and all the supervisors were instructed to warn their team members that it is a violation to have any space heaters in any office. The Security Supervisor has been instructed go through each office during his rounds and to make spot inspections to ensure compliance with regulations.
Completed: December 16, 2009 |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on the review of the facility's annual report for fiscal year July 1, 2008 through June 30, 2009, the facility failed to ensure that the annual report included a financial statement of income and expenses.
The findings include:
An interview was conducted with the Project Director on December 15, 2009. The Project Director confirmed that the financial statement of income and expenses was not documented on the annual report for July 1, 2008 to June 30, 2009.
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Plan of Correction
NHS will make unaudited financial reports specific to Parkside Recovery Philadelphia in future annual inspections. NHS will continue to also make audited statements available.
Completed: January 13, 2010 |