INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on BioCare Recovery Centers by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, June 27, 2014 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 a review of a personnel record, the facility failed to ensure that clinical supervisors who have not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision.
The findings include:
One personnel record was reviewed for documentation that a core curriculum in clinical supervision was completed for a clinical supervisor who has not functioned for 2 years as a supervisor in the provision of clinical services on June 27, 2014. The facility failed to ensure that a clinical supervisor completed a core curriculum in clinical supervision in one of one personnel record reviewed, specifically, personnel record #2.
Employee # 2 was hired as a clinical supervisor on November 22, 2013. Based on employee # 2's resume, employee #2 does not have experience functioning as a supervisor in the provision of clinical services. Therefore, employee #2 was due to complete a core curriculum in clinical supervision upon employment in his current position.
This was confirmed by the project director and clinical supervisor.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs and an interview with the project director, the facility failed to document that a fire alarm or smoke detector during each fire drill.
The findings include:
The fire drill logs were reviewed on June 27, 2014 for the time period covering November 2013 through May 2014. The facility failed to document on the fire drill logs that a smoke detector or fire alarm had been set off from November 2013 through May 2014.
When interviewed the facility director advised that they do set off an alarm but did not document it.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include the type and frequency of treatment services.
The findings include:
Six client records were reviewed for treatment plans on June 27, 2014. Two out of six client records lacked documentation of a treatment plan that included the type and frequency of treatment services, specifically client records # 3 and 4.
The treatment plan for client #3 was completed on June 23, 2013 and did not include the type and frequency of treatment services.
The treatment plan for client #4 was completed on June 17, 2014 and did not include the type and frequency of treatment services.
The findings were confirmed with the clinical supervisor.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include the proposed type of support services.
The findings include:
Six client records were reviewed for treatment plans on June 27, 2014. Six out of six client records lacked documentation of a treatment plan that included the proposed type of support services, specifically client records # 1, 2, 3, 4, 5, and 6.
The treatment plan for client #1 was completed on March 28, 2014 and did not include the proposed type of support services
The treatment plan for client #2 was completed on February 27, 2014 and did not include the proposed type of support services.
The treatment plan for client #3 was completed on June 23, 2013 and did not include the proposed type of support services.
The treatment plan for client #4 was completed on June 17, 2014 and did not include the proposed type of support services
The treatment plan for client #5 was completed on March 26, 2014 and did not include the proposed type of support services.
The treatment plan for client #6 was completed on March 3, 2014 and did not include the proposed type of support services
The findings were confirmed with the clinical supervisor.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |