INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 20, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection The Behavioral Wellness Center at Girard Torre de la Raza., 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 personnel records, the facility failed to ensure that clinical supervisors who have not functioned for two years as a supervisor in the provision of clinical services completed a Department-approved core curriculum in clinical supervision in one of one applicable personnel record reviewed.
Employee #3 was hired as a clinical supervisor on February 6, 2023 and did not have two years of clinical supervision experience prior to being hired. There was no documentation of a Department- approved curriculum in clinical supervision training in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1 Director of Residential Services will monitor completion of clinical supervisor(s) 12 clock education training hours annually
2 Clinical Supervisor(s) will follow their individual training plan.
3 Clinical Supervisor(s) will attend trainings required as per 704.11 Staff development program
4 Clinical Supervisor(s) will turn in their training certificates into Residential Services to be file in personnel file
5 Director of Residential Services will audit Clinical Supervisor(s) personnel file quarterly for training hours
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705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on a physical plant inspection conducted on September 20, 2023, between 9:30 AM and 12:30 PM, the facility failed to ensure that in each residential facility bedroom, each resident shall have a fire-retardant mattress that is in good repair.
In bedroom 705, there was a mattress that was ripped and not in good repair.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Support staff (Addiction Recovery Assistant and housekeeping) will inspect mattress condition upon each participants discharge.
a. Responsible party ? Residential Clinical Supervisors, Operations, House keeping
b. Completion date 10-1-23
Support staff will inform operations and facility supervisor by email and phone outreach to remove and replace any not in good repair
a. Responsible party ? Residential Clinical Supervisors, Operations, House keeping
b. Completion date 10-1-23
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on September 20, 2023, between 9:30 AM and 12:30 PM, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
The following bathrooms were found to not be functional, clean, or sanitary at the time of the inspection:
-Bathroom in room 702 had the appearance of mold
-Bathroom on 6th floor in room 9 had the appearance of mold.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will been retrained and disciplined for strict adherence to cleaning protocols with proper chemicals and tools. Follow up includes make sure that staff understand the importance of cleaning the showers properly and that they have the knowledge and skills necessary to do so.
-All shower caulking will be removed followed by applying new caulking
EVS supervisor will conduct weekly rounds on all unit showers and by tracking the satisfaction rates among patients and staff. This will be monitored for two months for 100% compliance.
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