INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on March 7, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Berks Counseling center, 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.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of employee training records on March 6, 2012, the facility failed to provide each employee with a written individual training plan in two of six personnel records reviewed..The findings include: A review of six employee training records on March 6, 2012 revealed that individual training plans for the year 2011 were missing in personnel records #1 and 2.
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Plan of Correction
Clinical Director will assume oversignt of individual training plans, assuring that all individual training plans are completed before the end of this fiscal year of June 30, 2012. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record log, the facility failed to document monthly fire drills. The findings includeThe fire drill record log was reviewed on March 7, 2012. The log was reviewed for drills documented from February 2011 through February 2012. The facility failed to conduct a fire drill in September 2011.
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Plan of Correction
Unfortunately that was the month BCC moved to our new location and the fire drill did not get held. BCC's Quality Improvement Health and Safety committee will assume oversight of assuring that fire drills are occurring every month at our main site at 645 Penn St. and at satellite site at 430 N. 2nd Street.
This will begin with April, 2012. |
705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant review, the facility failed to maintain protective caps over each electrical outlet.The findings include:Review of the physical plant on March 8, 2012, the facility failed to maintain protective caps on the electrical outlets in two areas utilized by children. One room provides service for child play and the second room is used for art therapy.
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Plan of Correction
Office manager purchased protective plastic caps, for electrical outlets, on March 8, 2012 - the day after the survey exit date. They have been placed in the electrical outlets in the two rooms designated for working with children as well as in the electrical outlets in all of the rooms used for treatment.
This was completed by March 12,2012.
BCC's Quality Improvement Health and Safety Committee will monitor ongoing compliance with regard to this standard. Individual counselors will check for compliance in the treatment rooms designated for children on a daily basis. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the annual report, the facility failed to make the annual report available to the public. The findings include:The annual report for the June 30,2010 to July 1, 2011 year was reviewed on March 8, 2012. The annual report was not made available to the public. The facility advertised an annual breakfast meeting in a local newspaper but failed to provide notification that the annual report was available to be reviewed by the public. This was discussed with and confirmed by the clinical supervisor on March 6, 2012.
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Plan of Correction
The Annual Report for BCC is always presented at the Annual Meeting which is a meeting attended by all BCC staff and open to the public. It is advertised in the local newspaper. The newspaper ad that will be announcing BCC's Annual Meeting, for the year 2012,will be amended to include the phrase "The Annual Report will be presented at BCC's Annual Meeting". This will provide notification of the availability for the public to review BCC's Annual Report. The 2012 Annual Meeting will take place in October of 2012. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical and psychiatric coverage.The findings include:The letters of agreement were reviewed on March 6, 2012. The only letter of agreement regarding 24-hour emergency medical coverage was signed with a local hospital in 2007. The agreement stipulated that it was in effect for two years and therefore expired in 2009. The clinical supervisor was interviewed on March 8, 2012. It was confirmed at that time that no other documentation of 24-hour emergency medical and psychiatric coverage was available.
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Plan of Correction
On March 12, 2012, a renewal of the current letter of agreement regarding 24-hour emergency medical and psychiatric coverage was submitted to the local hospital for signature by the designated hospital representative. A current signed letter of agreement with this local hospital was received April 9, 2012 with the local hospital in question. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel files and administrative policies and procedures, the facility failed to provide each employee with an annual individual performance review in one of six personnel records. The findings include:Six personnel records were reviewed on March 6, 2012. Personnel record #1 failed to include an annual individual staff performance review for employee #1 in 2011. A conversation with the Facility Director on March 7, 2012 confirmed an annual individual staff performance review was not completed for personnel #1 in 2011.
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Plan of Correction
The Human Resource Specialist has oversight of the annual evaluations that are required. She notifies the supervisor, via e-mail, of the pending evaluation one month prior to it's due date. Beginning with the month of April,2012, she will also e-mail the supervisor of the evaluator. This Supervisor will be responsible for ensuring that the annual evaluation gets completed and completed on time. BCC's Clinical Director will also be copied this e-mail to provide additional oversight and assurance. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to display a telephone number that can be accessed by the general public in case of an emergency.The findings include:A physical plant inspection was conducted on March 8, 2012. A telephone number that is conspicuously displayed to the general public is required at all outpatient treatment programs. The facility did not display an emergency telephone number that was accessible to the general public.
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Plan of Correction
BCC's emergency telephone number was displayed in our reception area and onthe outside of the office main door on March 8, 2012 and is accessible to the general public.
Support Services Coordinator will assume responsibility for ensuring compliance with this regulation continues. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of the staffing requirements facility summary report and active client list, the facility failed to notify the Department of a change in authorized maximum capacity.The findings include:The staffing requirements facility summary report was reviewed on March 8, 2012. The summary report, signed by the Project/Facility Director, indicated the facility had 284 current clients. The facility is licensed by the Division for a maximum client capacity of 275.The Facility Director generated an active client list on March 8,2012. The active client list had 284 current clients. The Facility Director acknowledged that the facility was currently over the authorized client capacity of 275.
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Plan of Correction
A letter of request to increse our capacity by 75 clients was submitted to the Division of Licensing on April 2, 2012. The maximum client capacity will increase to 350.
The capacity at BCC's treatment site at the prison changes on an ongoing basis. Program coordinator of this site will monitor the capacity quarterly to ensure we continue to be in compliance with this regulation.
In the future an additional request for increase in capacity will be submitted if the curent increase of 75 does not meet capacity. |