INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 16, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, WPIC Center for Psychiatric and Chemical Dependency Services 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(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 facility ' s Staffing Requirement Facility Summary Report (SRFSR), the project failed to have a full-time clinical supervisor for every eight full-time counselors and/or counselor assistants.
The full-time equivalent (FTE) calculation for the number of clinical supervisors needed is as follows:
The total # of hours project-wide devoted to D&A clients divided by the project ' s standard workweek.
The project calculation was: 1198 hours / 40 hours = 29.95 FTE.
The project must have a full-time clinical supervisor on staff for every 8 FTE clinical staff. Based on the FTE calculation, the project is required to have three full-time clinical supervisors. Based on the SRFSR, the project currently employs two full-time clinical supervisors.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director received approval to promote a lead staff into a supervisor position. Supervisor started 7/19/24.
Program director will monitor monthly the staffing ratio so this deficiency will not occur in the future, effective 8/5/2024 |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the facility's fire drill log for the months of July 2023 through June 2024, the facility failed to conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts. Eight out of eleven fire drills were conducted between 10:00am and 10:33am.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program supervisor educated facility staff on 7/19/24 regarding the requirements for conducting fire drills on different days of the week, different times of the day, and during different staffing shifts. Program supervisor is monitoring fire drills on a monthly basis. A fire drill was conducted in the afternoon on 7/31/24. |
711.96(a) LICENSURE Written Termination Notice
711.96. Notification of termination.
(a) The project director shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on applicable client records reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate the client's treatment in one of three client records.
Client #4 was admitted on October 27, 2023 and discharged on March 1, 2024. There was no documentation in the client record notifying the client in writing of termination from the project.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program supervisor educated staff on 7/16/24 during a staff meeting regarding the requirement to notify a patient in writing of the decision to terminate services. Program supervisor will monitor termination letters being sent during monthly chart audit reviews, effective 8/1/2024. |