INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the December 14, 2009 through December 15, 2009 licensure renewal inspection. The follow-up inspection was conducted on May 17, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 June 12, 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 one of three clinical supervisors where required.
The finding includes:
Three personnel records were reviewed on May 17, 2010. Documentation of core curriculum training in clinical supervision was required in three of three clinical supervisors' personnel records.
Employee #3 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 May 17, 2010, there was no documentation of the core curriculum training in personnel record #3.
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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. Program Director will registering the clinical supervisor who needs the clinical supervisors training. The Program Director will use BDAP Training Management System to register the supervisor. Program Director has contacted DOH/BDAP for upcoming training dates.
Corrective Action Date: Contacted BDAP June 14th for dates of next BDAP training session. |
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
Due to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction
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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
Due to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction
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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 |
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
Due to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction
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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: Immediately |