INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 4-5, 2014 by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Pathways to Recovery Counseling and Educational Services 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(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 personnel records on November 4-5, 2014, the facility failed to document the completion of 12 clock hours of annual training required for each clinical supervisor in one personnel record.
The findings include:
One personnel record required documentation of the completion of 12 clock hours of annual training for the clinical supervisor. The facility failed to document 12 clock hours of annual training in personnel record # 2.
The facility training year is from July 2013 through June 2014. Employee # 2 had documentation of 2 hours of training provided by an outside trainer.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The issue of annual training hours has been discussed with the Clinical Supervisor. As of December 1, 2014 the Clinical Supervisor has 36 documented training hours for the 2014-15 training year. Her annual training hours will be monitored by the Facility Director to ensure future compliance. |
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, the facility failed to document the completion of 25 clock hours of annual training required for each counselor.
The findings include:
Personnel records were reviewed on November 4-5, 2014. The facility failed to document 25 clock hours of annual training in personnel record #3.
Employee # 3 only completed 24 clock hours of annual training from July 2013 through June 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The issue of annual training hours has been discussed with Employee #3. As of December 1, 2014 the Employee #3 has 6 documented training hours for the 2014-15 training year and 18 hours scheduled. Employee #3's annual training hours will be monitored by the Clinical Director ensure future compliance. |
709.81(a)(3) LICENSURE Intake and admission
709.81. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(3) Requirements for completion of treatment.
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Observations
Based on a review of client records, the facility failed to document a consent to treatment and psychosocial evaluation in one out of two client records, as required.
The findings include:
Two client records were reviewed on November 4-5, 2014. The facility failed to provide documentation in client record # 2.
Client # 2 was readmitted to the program on 2-25-14 after being discharged 1-17-14. Client record # 2 did not include an updated consent to treatment form or psychosocial evaluation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On November 10, 2014 the Clinical Director addressed the issue of securing updated consents and completing psychosocial evaluations on all clients who are re-admitted to services. The Clinical Director followed the discussion with a written memo on the topic. The Clinical Director will monitor all clients who are re-admitted to services to ensure compliance in the future. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of two client records, the facility failed to document required treatment plan updates in one of the two records.
The findings include:
Two client records were reviewed on November 4-5, 2014. Two of the client records were from the partial hospitalization activity.
Client # 2 was admitted on 2-25-14 and discharged on 7-11-14. The client record was missing documentation of updated treatment plans which were due 5-7-14 and 6-7-14.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On November 10, 2014 the Clinical Director reviewed documentation standards as they pertain to treatment review plans and the need to complete them within the required time frame. The Clinical Director followed the discussion with a written memo on the topic. The Clinical Director will randomly monitor all charts on a monthly basis to ensure compliance. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of eight client records, the facility failed to document a consent to treatment and psychosocial evaluation in one out of eight client records, as required.
The findings include:
Eight client records were reviewed on November 4-5, 2014. The facility failed to provide documentation of a consent to treatment and psychosocial evaluation. in client record # 6.
Client # 6 was readmitted to the program on 7-7-14 after being discharged 5-30-14. Client record # 6 did not include an updated consent to treatment form or psychosocial evaluation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On November 10, 2014 the Clinical Director addressed the issue of securing updated consents and completing psychosocial evaluations on all clients who are re-admitted to services. The Clinical Director followed the discussion with a written memo on the topic. The Clinical Director will monitor all clients who are re-admitted to services to ensure compliance in the future |