INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 13, 2010 through September 16, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mirmont Treatment Center 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 October 21, 2010.
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Plan of Correction
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704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personal records and staff interview, the facility failed to provide documentation of at least 12 clock hours of annual training for the facility's January to December 2009 training year.
The finding include:
Fifteen personnel records were reviewed on September 15, 2010. Of those fifteen records, four records were those of clinical supervisors, which required at least 12 annual training hours. One out of four records did not have the required 12 hours documented. Personnel record # 5 only had documentation of 1 hour of training for the facility's 2009 training year.
During an interview with the facility's Human Resources representative, she explained some training documentation has become electronic and the electronic system did not document the number of hours of each training attended. This was noted as an area of deficiency that will need to be corrected within their electronic system.
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Plan of Correction
The Clinincal Director and the Staff Growth & Development Committee will conduct a quarterly audit of ClinicalSupervisor training records to ensure compliance with the requred 12 annual training hours.
The results of the audit will be reported at the quarterly Performance Improvement Meeting. Any Clinical Supervisor who has not met the pro-rated quarterly target (3 hours/quarter) will meet with the Clinical Director to develop a written plan for compliance before the end of the calendar year.
The next audit will be presented at the Performance Improvement Meeting October 13, 2010. Any Clinical Supervisor not meeting the requirements will meet with the Clinincal Director witin 1 week of the meeting to present his/her written plan to be completed before the end of the claendar year. |
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
Based on a review of personnel records and staff interview, the facility failed to provide documentation of at least 25 clock hours of annual training for the facility's January to December 2009 training year.
The finding include:
Fifteen personnel records were reviewed on September 15, 2010. Of those fifteen records, three records were those of counselors, which required at least 25 annual training hours. One out of three records did not have the required 25 hours documented. Personnel record # 12 only had documentation of 15 hours of training for the facility's 2009 training year.
During an interview with the facility's Human Resources representative, she explained some training documentation has become electronic and the electronic system did not document the number of hours of each training attended. This was noted as an area of deficiency that will need to be corrected within their electronic system.
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Plan of Correction
The Clinical Supervisor and the Staff Growth & Development Committee will conduct a quarterly audit of the counselor's training records to ensure complaince with the required 25 annual training hours.
The results of the sudit will be reported at the quarterly Perfoemance Improvement meeting. Any counselor who has not met the pro-rated quarterly target (6-8 hours/quarter) will meet with his/her Clinical Supervisor to develop awritten plan for compliance before the end of the year.
The results of the audit will be presented at the October 13, 2010 Perfomance Improvement meeting. Any counselor with pro-rated deficiencies shall meet with his/her Clinical Supervisor within 1 week to develop a written plan for compliance before the end of the claendar year. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personal records, the facility failed to provide documentation of fire extinguisher training upon staff employment in four out four of personnel records reviewed.
The finding include:
Fifteen personnel records were reviewed on September 15, 2010. Of those fifteen records, four personnel were new hires. Fire extinguisher training in personnel records # 8, 9, 14, 15 was not documented upon employment.
Staff # 8 was hired on 6/28/10 and fire extinguisher training was documented on 7/13/10. Staff # 9 was hired on 4/26/10 and fire extinguisher training was documented on 7/28/10. Staff # 14 was hired on 5/31/10 and fire extinguisher training was documented on 6/21/10. Staff # 15 was hired on 5/17/10 and fire extinguisher training was documented on 7/15/10.
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Plan of Correction
Mirmont's current fire safety/fire extinguisher orientation training is via a computer based training module. The deficiencies listed are due to the new hires not being registered into the system at the time of orientation. In order to ensure compliance with this standard, any new employee who is not registered in the computer based system will complete a paper copy of the training on orientation. This hardcopy will be signed/dated and maintained in the new hire's staff growth and development file by the Staff Growth and Development Trainer.
This plan is in operation as of 9/27/2010. The Staff Growth and Development Trainer will complete and audit quarterly and report findings at the quarterly Performance Improvementmeeting for compliance. The next compliance report is 10/13/10 |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based upon review of fire drill records, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
Findings include:
According to facility policy, sleeping hours are from 11:30 PM until 6:30 AM. Documented fire drill records showed the date of the last drill conducted during sleeping hours to be 9/20/09 at 6:05 AM.
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Plan of Correction
The Safety Officer or designee who supervises all fire drills will ensure that the nighttime drills at Mirmont will be held prior to the wake-up time of 6:30 AM.
All fire drill information will be reported and reviewed at the Safety/Infection Control meeting for monitoring of correct shifts and times throughout the year to ensure complaince.
The next nighttime drill is scheduled for Saturday, October 16, 2010 at 6AM |