INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 5 through September 6, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on October 5, 2006.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Counselor did not meet the required number of training hours in three of three records reviewed, #3, 5 and 6.
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Plan of Correction
Effective immediately (the form was created during the licensing visit)the Program Director has placed a form in each individuals personnel file that will document trainings attended. The date and hours of the training will be entered on the form when a certificate is turned in, and only when a certificate is turned in. Full compliance will be no later than June 30, 2007 which is the end of the training year.
The Program Director will review each training form quarterly to make sure that each person is working towards, or has obtained, at a minimum, the required training hours.
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704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
The counselor assistant did not meet the required training hours, #4.
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Plan of Correction
The facility and Counselor Assistant were not in compliance with this standard because either all training documentation was not turned in or because supervisory staff did not properly monitor training.
The facility will be in full compliance by the end of the fiscal 2006-2007 training year (June 30, 2007).
The Program Director has created a staff training form that is in each persons file. This form will document all trainings attended, and for which a certificate has been turned in. If a certificate is not turned in the trsaining will not be documented on the list. The Director shall monitor these reports on a quarterly basis to make sure that this person, and all staff, are attending appropriate trainings and that they are receiving the required training hours. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
The exhaust fans in two bathrooms on the women's side of the building were not operable.
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Plan of Correction
The situation shall be corrected and the facility shall be in full compliance with this standard by October 31, 2006.
The fans will be replaced by October 31, 2006.
The Program Director will personally make sure that the fans are replaced by the date listed above. |
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
One bathroom on the men's unit had a leak in the ceiling causing water on the floor.
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Plan of Correction
Full compliance by January 31, 2007, although it is assumed that the problem shall be corrected much sooner.
The building owner sent a roofer out to inspect the roof. He stated that he would report his findings to the owner the same day.
The Director will pass on to the Board any and all actions the owner will take to correct the problem no later than their October 9, 2006 meeting.
The Program Director and the Board of Directors shall be responsible for making sure that the roof is repaired and that the program is in full compliance.
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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
The written agreement for 24-hour emergency medical coverage was missing.
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Plan of Correction
Harwood House will request a specific 24 hour emergency medical coverage from Delaware County Memorial Hospital no later than October 15, 2006.
The Program Director will make the request and make sure that the facility is in compliance with this standard. |
709.26(a)(9) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(9) Supervision of staff.
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Observations
The policy and procedure for the supervision of staff was missing.
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Plan of Correction
Achieved. A Policy was developed and shown to the licensing specialist. It was approved by the Board of Directors at their September 11, 2006 meeting and placed in the manual.
The Program Director presented the new Policy to the Board and, upon approval, placed it in the policy and Procedures Manual. |
709.52(a)(3) LICENSURE Support service type
709.52. 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
Support services were not documented in four of five client records reviewed, # 1, 2, 3 and 4.
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Plan of Correction
Compliance by November 30, 2006. All supportive services used or suggested shall be documented on each treatment plan. At the least, this will begin with all admissions after September 6, 2006.
The Clinical Supervisor will ensure compliance. The Program Director will review each treatment plan when re-authorizations are due (at least monthly). Any plans that do not correctly document support services shall be corrected. |
709.53(a)(2) LICENSURE Medication records
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(2) Medication records.
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Observations
Medication records were missing the dose and frequency in two of six client records reviewed, #1 and 3. In addition, the program's policy on medication non-compliance was not followed in client record #9.
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Plan of Correction
Compliance by November 30, 2006. Beginning with all new admissions the medication, dosage, and frequency shall be documented on all Medication Sheets.
Program policy for medication non-compliance shall be followed.
The Program Director shall ensure compliance to this when he does monthly re-authorizations and chart reviews. Medication Compliance shall be reviewed weekly during medication card checks. Policy shall be followed! |