INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 4, 2015 through February 5, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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:
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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
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to obtain and document the completion of 12 clock hours of annual training required for the project director and the facility director in one of six records reviewed.
The findings include:
The SRFSR was reviewed on January 28, 2015 and re-reviewed on February 4, 2015. Six personnel records were reviewed on February 4, 2015. One personnel record pertained to the project director and facility director, which is the same person. The project director/facility director are required to complete at least 12 clock hours of annual training. The facility failed ensure that the project director/facility director obtained and documented at least 12 clock hours of annual training in employee record #1 .
Employee #1 was hired as the project director and the facility director on November 6, 2006. The facility's training year was from July 1, 2013 through June 30, 2014. Employee #1 only had 10 clock hours documented on the SRFSR and in the personnel record for the 2013-2014 training year.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
A home study training was scheduled to be submitted prior to June 30, 2014. However the Executive Director failed to submit it until after the training year ended.
The Executive Director will assure that 12 hours or more training will be completed within the fiscal year for any supervisory position. The Executive Director will review the training plan quarterly to assure that the trainings are completed in a timely manner. |
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 the Staffing Requirements Facility Summary Report (SRFSR) and the personnel records, the facility failed to obtain and document the completion of 25 clock hours of annual training required for counselors in two of six records reviewed.
The findings include:
The SRFSR was reviewed on January 28, 2015 and re-reviewed on February 4, 2015. Six personnel records were reviewed on February 4, 2015 and three records pertained to counselors. However, only two personnel records were required to have the regulated training hours. The facility failed ensure that the counselors obtained and documented at least 25 clock hours of annual training in employee records #5, and 6.
Employee #5 was hired as a counselor on September 20, 2010. The facility's training year was from July 1, 2013 through June 30, 2014. The facility only had 9.5 clock hours documented on the SRFSR and in the personnel record for the 2013-2014 training year for employee #5.
Employee #6 was hired as a counselor on September 1, 2008. The facility's training year was from July 1, 2013 through June 30, 2014. The facility only had 14 clock hours documented on the SRFSR and in the personnel record for the 2013-2014 training year for employee #6.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
A home study training was scheduled to be submitted prior to June 30, 2014. However the Executive Director failed to submit it until after the training year ended.
The Executive Director will assure that 25 hours or more training will be completed within the fiscal year for any clinical position. The Executive Director will review the training plan quarterly to assure that the trainings are completed in a timely manner. |