INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on May 28, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, RHD - Womanspace 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(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 each clinical supervisor or lead counselor who had not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision in one of one applicable personnel records.
Employee # 2 was hired as a clinical supervisor on December 3, 2017. There was no documentation of the a DDAP-sponsored or DDAP-approved clinical supervision training on file at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will review the standards with the employee and utilize yearly training plan and individual supervision to ensure that employees in the position of clinical supervisor obtain the training to meet the core curriculum standards.
Facility Director will review credentials and experience of all potential clinical supervisors. For all individuals not meeting the minimum service requirement, registration in a DDAP sponsored clinical supervisor training will be ensured before being given a start date to function in the role of clinical supervisor to ensure that the requirement is met. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records, the facility failed to ensure that all personnel records included documentation of an annual written individual performance evaluation in one of four applicable employee records reviewed.
Employee # 1 was hired as the Facility Director on December 3, 2017. The annual written individual performance evaluation signed by the reviewer on August 19, 2019 was incomplete and was not signed by the supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regional Director of Addiction Services for Resources for Human Development will meet with Program Director by June 30, 2020 to complete annual written performance evaluation and will ensure that written performance evaluations for the program director are completed by June 30th of each fiscal year. Facility Director will review personnel charts quarterly to ensure that all employees receive yearly written performance evaluations. |