INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 26, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Recovery Revolution, 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:
|
Plan of Correction
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of personnel records, the facility failed to ensure that all staff received at least 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics training, within the regulatory time frame, in one of one applicable personnel record reviewed.
Employee #3 was hired as a counselor on April 1, 2022. The TB/STD training and the HIV/AIDS training were due no later than April 1, 2023; however, the TB/STD training was not completed as of the date of the inspection and the HIV/AIDS training was not completed until June 29, 2023.
These findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Recovery Revolution has training plan for each individual staff. The Executive Director will assure that both HIV and STD is done within the first year for clinical staff and acquire old certificates if a person has taken it prior to their employment.
At time of inspection, the HIV for Employee was not in the chart. This certificate was emailed on 3/7/2024. Employee 3 took HIV/AID was taken on August 14, 2014 prior to her employment with us and took it again with us for 6 more hours. This has been provided to our licensing specialist.
Employee 3 is on 3 waiting list for STD/TB however since ED has to assure that it is done, we decided to pay for it online. Using the suggestion by licensing specialist, the Executive director found online courses through Relias Academy. 4 hours of courses in TB, ST, and other health related topics was purchased. Employee 3 will complete these courses by June 30th, 2024 |
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 hours of annual training, during the facility's January 2023 through December 2023 training year, in one of four applicable personnel records reviewed.
Employee #6 was hired as a counselor on July 8, 2021. The personnel training record documented 12.5 hours of annual training for the training year reviewed.
These finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Employee 6 was out on medical leave throughout the 2022-23 FY and was not employed at the end of the fiscal year and it was unclear at time if she would return. Recovery Revolution failed to document her employment seperation in the employee file in June 2023. The ED identified this issue in the review of the 2022-23 as documented in the overview 2023-24 training plan evaluation. ED met with employee 6 in January 2024 to discuss her 25 hours needed. This employee needs 40 yours for recertification and has more than 25 hours at the site inspection. The ED already addressed this issue and staff is on track. Recovery Revolution's Executive Director will continue to do individual and companywide training plans and document any staff seperation in the employee chart. |