INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 16-17, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, The Program for Offenders, 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
The facility failed to document that the project director completed at least 12 clock hours of training for the 2018 training year.
Personnel and training records were reviewed on June 26-28, 2019 during an administrative review for the project. The project director, employee #1, had 6 hours of training documented for the January - December 2018 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff including the Executive Director will obtain the required number of trainings per staff requirements. In this case, the Executive Director will receive at least 12 hours of training each year. This will be reviewed by the Training Coordinator halfway through each calendar year to ensure that prior to monitoring, all staff have obtained the appropriate training hours and that documentation has been stored in the training binders. Further reviews will be completed periodically by the Training Coordinator and Clinical Supervisor/Manager to ensure Staff are meeting their requirements. |
709.42(a) LICENSURE Written Procedures/Proj Mngt
709.41. Exceptions to the general standards for free-standing treatment activities.
Due to the nature of intake, evaluation and referral, projects of this kind need not comply with the following sections:
(1) Section 709.24(a)(2) and (3) (relating to treatment/rehabilitation management).
(2) Section 709.33 (relating to notification of termination).
709.42. Project management.
(a) The intake project shall have a written procedure for the performance of the following functions:
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Observations
The facility failed to document written procedures for the performance of Intake, Evaluation and Referral functions.
The policy and procedure manual was reviewed on July 16-17, 2019. At the time of the inspection there were no policies and procedures for the Intake, Evaluation and Referral activity.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
TPFO's Policy Expert and Clinical Director will develop a written procedures for the performance of Intake, Evaluation and Referral functions and will include all required information as outlined by policy. This will be completed by 10/1/2019. The Clinical Director will be responsible for ensuring the corrective action is implemented and that the policies have been created appropriately. This will be completed by 10/1/2019. |
709.43(a) LICENSURE Communication with authorities
709.43. Client management.
(a) The intake project shall have written policies and procedures for communication with law-enforcement authorities, local or State health or welfare authorities, as appropriate, regarding clients whose condition or its cause is reportable; for example, persons having contagious diseases or victims of suspected criminal acts, such as rape or gunshot wounds, 18 Pa. C.S. 5106 (relating to failure to report injuries by firearm or criminal act) and child abuse under the Child Protective Services Law (11 P. S. 2201-2224).
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Observations
The facility failed to document a written policies and procedures for communication with law enforcement and Local/State health or welfare authorities regarding clients reportable conditions.
The policy and procedure manual was reviewed on July 16-17, 2019. At the time of the inspection, there were no policies and procedures for the Intake, Evaluation and Referral activity.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
TPFO's Policy Expert and Clinical Director will develop a written policies and procedures for communication with law enforcement and local/state health or welfare authorities regarding clients reportable conditions. This will be completed by 10/1/2019. The Clinical Director will be responsible for ensuring that the corrective action is implemented and that the policies and procedures are completed by 10/1/2019. |
709.43(b) LICENSURE Special Issues
709.43. Client management.
(b) The intake project shall have written policies and procedures to address special issues regarding treatment of clients. These policies and procedures shall include, but are not limited to:
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Observations
The facility failed to document written policies and procedures to address special issues regarding the treatment of clients.
The policy and procedure manual was reviewed on July 16-17, 2019. At the time of the inspection, there were no policies and procedures for the Intake, Evaluation and Referral activity.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
TPFO's Policy Expert and Clinical Director will develop a written policies and procedures to address special issues regarding the treatment of clients. This will be completed by 10/1/2019 and the Clinical Director will be responsible for ensuring the corrective action has been completed and implemented appropriately. |