INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 23, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services Gettysburg Psychiatric 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 March 17, 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 ' s administrative staff, 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 nine facilities that make up the project list a total of 59 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 30.69 FTE counselor and/or counselor assistant positions within the project.
The " Staffing Requirements Facility Summary Reports " for each of the nine facilities within the project revealed that no employees were listed as full-time clinical supervisors. A full-time equivalency of 30.69 counselors and/or counselor assistants requires a minimum of 3 full-time clinical supervisors within the project.
The Executive Director is listed as the Project Director (designated as employee # 1 for facility number 367070) and as the Facility Director for facility numbers 227059, 387012, and 677044 and cannot also act as a full-time clinical supervisor. The person listed as the Facility Director for facility numbers 067079, 217049, 017068, 367070 and 067058 (designated as employee # 2 for facility number 367070) cannot also act as a full-time clinical supervisor. The person listed as the Facility Director and clinical supervisor for facility number 387019 (designated as employee # 2 for facility number 387019) cannot also act as a full-time clinical supervisor.
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Plan of Correction
Pennsylvania Counseling Services submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State laws relating to drug and alcohol
treatment. This Plan of Correction should not be construed as either a
waiver of the facility's right to appeal or an admission of past or
ongoing violations of applicable regulatory requirements.
The Vice President of Quality Improvement and Director of Quality Improvement will ensure that there is one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors and/or counselor assistants in the entire Project. The Vice President of Quality Improvement and Director of Quality Improvement will ensure that these supervisors meet DOH staffing regulations for the position of full-time Clinical Supervisor. The Vice President of Quality Improvement and Director of Quality Improvement will also ensure that the Staffing Requirement Facility Summary Reports are completed accurately to reflect these supervisory hours for future inspections.
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all bathrooms had ventilation by an exhaust fan or window.
The finding includes:
The physical plant inspection took place on February 23, 2010 at approximately 9:30 am and an interview was conducted with the Director of Quality Improvement on the same day. There is one ladies restroom for clients. During the inspection it was observed that the exhaust fan was not working and was brought to the attention of the Director of Quality Improvement.
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Plan of Correction
The PCS Maintenance Department will install an exhaust fan in the ladies restroom for clients. The Director of Maintenance will oversee that all bathrooms have ventilation by exhaust fans or windows and that these mechanisms are working properly. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on the physical plant inspection, the facility failed to secure client records within locked storage containers.
The findings include:
The physical plant inspection took place on February 23, 2010 at approximately 9:20 am. The discharge records were stored in a locked storage room, but were not secured in locked storage containers. The storage room was also used for storage of holiday items and cleaning materials. The Director of Quality Improvement was interviewed and indicated that the holiday items and cleaning materials would be removed.
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Plan of Correction
All discharged records are now stored in a locked storage room without the presence of any miscellaneous items. The Quality Improvement Department will ensure that the archive room only be used to store client records via random on-site physical inspections. |