INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 18 and May 19, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Insights, 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 June 8, 2010.
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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 Director/ Facility Director 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 two facilities that make up the project list a total of 13 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 8.85 FTE counselor and/or counselor assistant positions within the project.
The " Staffing Requirements Facility Summary Reports " for each of the two facilities within the project revealed that no employee was listed as full-time clinical supervisors. A full-time equivalency of 8.85 counselors and/or counselor assistants requires a minimum of one full-time clinical supervisor within the project.
The Executive Director is listed as the Project Director and cannot also act as a full-time clinical supervisor.
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Plan of Correction
Clinical Supervisor Qualifications. A newly hired Clinical Director is projected to be in place by August 31, 2010. This individual will meet all the qualifications for this role, of full-time clinical supervisor. This Clinical Director will have a maximum of (5) five drug and alcohol clients on their caseload. The Executive Director is responsible for this task and will also develop a job description for this new position. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on the physical plant tour, the facility failed to ensure that all exits were not obstructed.
The findings include:
The physical plant tour was conducted between 1:00 p.m. and 1:30 p.m. on May 18, 2010. The facility failed to ensure that the secondary emergency exit on the second floor was unobstructed. The secondary emergency exit on the second floor was obstructed with a tarp and four wooden skids.
The project director confirmed that the items were obstructing the exit route to the stairs and agreed to remove the items immediately.
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Plan of Correction
The wooden skids were removed from the second floor deck area that serves as a secondary emergency exit. The Executive Director oversaw the removal of the skids on 5/18/2010. A staff memo was circulated to remind the staff of the importance of keeping the secondary emergency route free of any obstacles. The memo was generated on June 1, 2010 by the Executive Director. |
709.83(a)(6) LICENSURE Client records
709.83. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to follow the facility policy regarding aftercare plans in one of one required record.
The findings include:
Thirteen client records were reviewed on May 19, 2010. Four of the thirteen client records were from the partial hospitalization activity. One of those four records was required to include documentation of an aftercare plan. According to the facility policy and procedure manual, "the primary counselor and client will sign and date the aftercare plan". The facility failed to have the client sign the aftercare plan in client record # 2.
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Plan of Correction
The clinical supervisor will review with the counseling staff at the staff meeting on 6/23/2010 the requirements of completing an after care plan with each client at the client's last session. Both the counselor and the client are required to sign the after care plan. When each client is discharged, and the front office staff receives a discharge status form from the counselor, the front office will audit each chart to confirm that an after care plan has been completed by the counselor and signed by the counselor and client. The front office staff will report any noncompliance to the clinical supervisor. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of fiscal documents presented at the time of the inspection and an interview with the project director, the facility failed to document an annual audit of financial activities for the year ended 6/30/2009.
The findings included:
During the onsite licensing inspection conducted from May 18 and 19, 2010, the fiscal documents were reviewed. The facility director was interviewed about the annual audit and confirmed that an audit was not conducted for the fiscal year of 08/09.
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Plan of Correction
The Executive Director will request an exception to the requirement for an annual audit. This request will be filed by June 11, 2010. If the exception is not granted, the Chief Financial Counsel will secure the services of an independent public accountant by July 31, 2010. The audit will be conducted with results reported to the PA Department of Health by September 30, 2010. |