INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 7 - 9, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Soar Corp. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in ten of twenty-one client records reviewed. The findings included:Twenty-one client records were reviewed January 9, 2013. Twelve client records were reviewed regarding release of information documentation. Ten client records, # 1, 2, 3, 4, 5, 7, 8, 9 and 11 contained a consent to release information to the client's funding source that listed "concurrent reviews and/or authorization forms" as the information being released to the funder. These items were not specific enough to define what actual information was to be released to the funding source, therefore allowing for the exceeding of 4 PA Code 255.5, which restricts the information to be released to very specific and limited areas.
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Plan of Correction
The clinical team will review the PA State 255.5 for the proper wording on the release forms and make any changes necessary to be in compliance with the 255.5 code. All active SOAR clients will re-sign the new release forms on or before January 31, 2013. We drafted a new Release form and put into the intake packet as of January 24, 2013. The Ancillary Staff Manager and Clinical Supervisors will be responsible to see the corrected form are in all active client charts by January 31, 2013 |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill record, the facility failed to prepare alternate exit routes to be used during fire drills.The findings include:The fire drill record was reviewed on January 7, 2013. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. The facility did not document any alternate exits used during fire drills. The front door was the exit route used during every fire drill. The following months were reviewed; December 2011, January 2012, February 2012, March 2012, April 2012, May 2012, June 2012, August 2012, September 2012, October 2012, November 2012 and December 2012.An interview with the facility staff on January 9, 2013 confirmed the findings.
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Plan of Correction
A meeting with the Safety/Fire Safety committee will be set up for 1/30/2013. The only use of the Main Exit or front door is not to be used (as it is not spacific to the doors being used) in the preparation of the fire drills paperwork. 3 of the 4 doors are what could be called the front doors as only one is the main entrance. The terminology to be used will be (1) The Main entrance, (2) the Front Side Door, (3)the Front Fire Exit Door and (4) The Back Fire Escape Door.The Fire Captain will be responsible to keep the Fire and Safety Team aware of the use of the words to be used on the monthly reports.A meeting/training of the Fire and Safety Committee will be on or before 1/30/2013 by the Fire Captain. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's fire drill record and exception letter, the facility failed to show documentation of the facility's annual inspection of the fire alarm system.The finding includes:The fire drill record was reviewed on January 7, 2013 and the exception letter was reviewed January 8, 2013. The facility currently has an exception from setting off the fire alarm during fire drills. According to the exception that was granted by the Department on July 1, 2008, the facility must show documentation that the fire alarm system is in good working condition and must be inspected annually. That last time the alarm system was inspection was in 2011. An interview with the project director on January 11, 2012 confirmed the alarm system was not inspected in 2012.
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Plan of Correction
The Alarm Company will be contacted by 1/30/2013 to schedule an alarm check. Alert One Protection reset the alarm after the glass was broke by a patient but the documentation only state glass replaced on fire box. A formal inspection will be scheduled by 1/30/13. The Project Director will be responsible to have the system inspected and documented. The Executive Director will have the Alarm System scheduled to be checked along with the fire extinguishers every December. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in ten of twenty-one client records. The findings include:Twenty-one client records were reviewed on January 9, 2013. Ten client records was reviewed for psychosocial evaluations. The psychosocial evaluations in client records #3, 5, 6, 7, 9, 10 and 12 did not include an evaluation of the client's assets/strengths and how they would impact treatment. The psychosocial evaluations in client records #3, 5, 6, 7, 9, 10 and 12 did not include an evaluation of the client's support systems and how they would relate to treatment. The psychosocial evaluations in client records #3, 5, 6, 7, 9, 10 and 12 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment. The psychosocial evaluations in client records #3, 5, 6, 7, 9, 10 and 12 did not include an evaluation of the client's negative factors and how they would impact treatment. The psychosocial evaluations in client records #3, 5, 6, 7, 9, 10 and 12 did not include an evaluations of the client's attitude towards treatment and how it would impact their treatment.The psychosocial evaluations in client records #3, 5, 6, 7, 9, 10 and 12 did not include an evaluation of the counselor conclusions/impressions of the client. Also, per the facility policy, psychosocial evaluations are to be completed within 30 days of the client's admission date.Client #1 was admitted on December 6, 2012; the psychosocial evaluation was to be completed by January 6, 2013. At the time of the inspection, there was no documentation of client #1's psychosocial evaluation.Client #2 was admitted on December 7, 2012; the psychosocial evaluation was to be completed by January 7, 2013. At the time of the inspection, there was no documentation of client #2's psychosocial evaluation.Client #11 was admitted on December 3, 2012; the psychosocial evaluation was to be completed by January 3, 2013. At the time of the inspection, there was no documentation of client #11's psychosocial evaluation.
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Plan of Correction
The management team will review the psychosocial for the information required. The management team will review the psychosocial and see that all the information is filled out in every section.The review will take place on or before February 8,2013.
The review of the psychosocial will include evidence of questions on the client's support system and how they would relate to treatment, the information on the coping mechanisms if any and how it could impact treatment, the client's attitude towards treatment, a detailed evaluation from the counselor on their impression of the client, that the evaluation is completed within the 30 day window, as well as be in the client's chart within 30 days. The Clinical Supervisor's will be responsible to check that this is done on their monthly supervision. The Medical Records personal will also check that all the sections on the psychosocial is filled in. If any section is not filled in a list will be given to the supervisors. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document in the treatment plan update the client's progress as it related to the goals identified in the individualized treatment and rehabilitation plan.The findings were:Twenty-one client records were reviewed on January 9, 2013. Five client records were reviewed for treatment plan updates. Per the facility's policy, treatment plan updates are to be updated every 60 days after the comprehensive treatment plan. Treatment plan updates are to document an assessment of the client's progression in treatment as it relates to the goals identified in the individualized treatment and rehabilitation plan.Client # 3 was admitted on August 20, 2012; their comprehensive treatment plan was documented on September 13, 2012 and the treatment plan update was due November 13, 2012. As of the date of the inspection there was no documentation of the treatment plan update in client record #3.Client # 5 was admitted on October 1, 2012; their comprehensive treatment plan was documented on November 1, 2012. The treatment plan update was documented on January 1, 2013, but it did not document the client's progression in treatment as it related to the goals identified in the individualized treatment and rehabilitation plan. In addition, new goals were identified in the treatment plan update without documenting the progress of previous goals identified.Client # 6 was admitted on September 27, 2012; their comprehensive treatment plan was documented on October 25, 2012. The treatment plan update was documented on December 24, 2012, but it did not document the client's progression in treatment as it related to the goals identified in the individualized treatment and rehabilitation plan. In addition, new goals were identified in the treatment plan update without documenting the progress of previous goals identified.Client # 7 was admitted on August 7, 2012; their comprehensive treatment plan was documented on September 2012. The treatment plan updates were documented on November 5, 2012 and January 3, 2013, but they did not document the client's progression in treatment as it relates to the goals identified in the individualized treatment and rehabilitation plans. In addition, new goals were identified in the treatment plan updates without documenting the progress of previous goals identified.
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Plan of Correction
Treatment plans are to be updated every 60 days after the comprehensive treatment plan is done. The client's progress as it is related to the previous treatment goals is to be noted as each additional treatment plan is prepared. Treatment plans are to be updated every 60 days after the comprehensive treatment plan is done. The client's progress as it is related to the previous treatment goals is to be noted as each additional treatment plan is prepared. A scheduled training for all clinical staff on the preparation of treatment plans will be conducted on or before 2/15/2013. The Clinical Supervisors will be responsible to see that previous treament goals progress or lack their of is noted on the new treatment plan. The Clinical Supervisors will check charts for compliance at the monthly individual supervision sessions. The Medical Records staff will review that the treatment plans are done and in the client's chart in a timely manner.
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709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to include all required components in the discharge summary in nine of nine client records.The findings include:Twenty-one client records were reviewed on January 9, 2013. Nine discharge client records were required to have documentation of a discharge summary, #13, 14, 15, 16, 17, 18, 19, 20 and 21. The following components are required to be documented on the discharge summary; reason for treatment, services offered, respond to treatment and client status. The facility failed to include reason for treatment, support services, client's response to treatment and client status at the time of discharge on the discharge summary for client's #13, 14, 15, 16 and 19. Also, the facility failed to include the reason for treatment on the discharge summary for client's 17, 18, 20 and 21. An interview with the facility director on January 9, 2013 confirmed the findings.
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Plan of Correction
Discharge summary - The required components i.e.: reason for treatment, the services offered, how a client responded to treatment and the clients present status, as well as the support services that were offered during treatment. SOAR will provide training on the preparation on D/C summaries on or before 1/30/2013 for all clinical staff. The summaries are not to be generic. The Clinical Supervisor will be responsible to check that the D/C summaries are being done during the individual staff supervision. The Medical Records staff will check all client charts for the summary and notify the Clinical Suppervisor or any missing summaries. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on client record review, the facility failed to document a follow up attempt in four of nine discharge client records.The findings include:Twenty-one client records were reviewed on January 9, 2013. Nine discharge records were reviewed. A follow up attempt was required in four of the nine discharge client records. The facility did not document a follow up in four client records, #13, 14, 15 and 16. The facility policy stated that follow up will be attempted within seven days for referrals, 30 days for all other discharges. An interview with the facility director on January 9, 2013 confirmed the findings.Client #13 was admitted on September 17, 2012 and discharged on October 16, 2012. The follow-up attempt was to be documented by November 16, 2012. There was no follow-up attempt documented in client record #13.Client #14 was admitted on August 20, 2012 and discharged on September 8, 2012. The follow-up attempt was to be documented by October 8, 2012. There was no follow-up attempt documented in client record #14.Client #15 was admitted on August 3, 2012 and discharged on September 24, 2012. The follow-up attempt was to be documented by October 24, 2012. There was no follow-up attempt documented in client record #15.Client #16 was admitted on August 6, 2012 and discharged on November 13, 2012. The follow-up attempt was to be documented by December 13, 2012. There was no follow-up attempt documented in client record #16.
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Plan of Correction
All discharge Follow-ups ? All referrals clients will have a follow-up within 7 days of Discharge documented and put in the client's chart by the counselor. All 30 and 90 day follow-up records will be compiled in a ring binder for the current year for 30 day and 90 day follow-ups. This will be assigned to a staff member to send out mail to all patients discharged in 30 and 90 days from the discharge date. A Excel file will be generated with 8 questions for statistics. 1) Is client still in recovery? 2) Have relapsed since D/C. 3) Attends 12 step program. 4) Has a support group. 5) Has a job. 6) Was arrested since D/C? 7) Life has improved since D/C. 8) General wellbeing as poor, fair or good. The counselor will be responsible for client Referred to another facility within 7 days. A designated staff person will log all 30 and 90 day follow-ups in a binder by calendar year. A copy of the letter sent out will be filed along with a return letter from any client who returns the questionnaire. The designated person will be responsible to see the 30 - 90 dayfollow-ups are done. The Director of Ancillary staff will be responsible to oversee the ring binder is up to date quarterly. This will be in place by 1/31/2013.
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on the review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in two of twelve record reviewed.Findings:Eighteen personnel records were reviewed on January 8, 2013. Twelve of the eighteen personnel records were reviewed for the counselor position, #5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16. Personnel records #10 and 16 did not meet the requirements for counselor. Employee #10 was hired on November 28, 2011 as a counselor assistant and promoted on September 28, 2012 to a counselor. Employee #10 did not have a year of clinical experience prior to employment and was a counselor assistant for only ten months prior to the promotion to counselor. In accordance with the regulations, a counselor who has a bachelor degree must have at least 1 year of clinical experience to meet qualifications for a counselor. Employee #10 was promoted two months before their one year experience was completed.Employee #16 was hired November 15, 2012 as a counselor. Employee #16 did not have the required one year clinical experience and did not meet the qualification for a counselor. Per the State standards, a counselor who has a bachelor degree must have at least 1 year clinical experience to meet qualifications for a counselor.An interview with the facility director on January 9, 2013 confirmed the findings.
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Plan of Correction
Employee #10 was promoted 2 months prior to the one year requirement. She will be supervised for two more months for compliance for January and February 2013 to become compliant with the regulations.
Employee #16 We have varification of employment working in the D&A field. But we are starting this counselor as of January 2013 as an assistant counselor acording to the State regulations with a year to be compliant with the state regulations.
All new staff appling to SOAR CORP for employment will be interviewed by at least 3 staff. One will be the HR director and the others will have at least one clinical and one supervisory staff at the interview. The licensing alert update 4-98 and 2-02 will be followed under 28 PA Code Chapter 704. A copy of the 28 PA Code Chapter 704.7 and 704.8 will be displayed at the interview, as well as Alert 4-98and 2-02 August 2008. The HR Director and one clinical staff will be responsible to check the resume for compliance. Assistant counselor will have to prepare a specifically addressed plan to achieve counseling competency in chemical dependency.This will be in effect at SOAR CORP by 1/30/2013. |
704.8(c) LICENSURE Full Caseload Assignment
704.8. Qualifications for the position of counselor assistant.
(c) In addition to training, assignment of a full caseload shall be contingent upon the supervisor's positive assessment of the counselor assistant's individual skill level.
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Observations
Based on a review of personnel records, the facility failed to show a positive assessment prior to the counselor assistant receiving a full caseload in one of two counselor assistant personnel records.The findings include:Eighteen personnel records were reviewed on January 8, 2013. Two of the eighteen personnel records were reviewed for counselor assistant, #17 and 18. In accordance with the regulations, assignment of a full caseload shall be contingent upon the supervisor's positive assessment of the counselor assistant 's individual skill level.Employee #18 was hired as a counselor assistant with a high school diploma on August 3, 2012. During the review of employee #18's personnel record there was no documentation of a supervisor's positive assessment. Employee #18 had a full caseload of 35 active clients.An interview with the facility director on January 9, 2013 confirmed that findings.
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Plan of Correction
Assistant Counselor #17 Is no longer an assistant counselor at SOAR. Any clients on that case load were transferred to another counselor January 24, 2013.
Assistant Counselor # 18 had his case load reduced from a full case load on January 24, 2013.The Supervisor will submit a letter of positive counseling practices.He does not have a full case load and will not as long as he is an assistant counselor.
AN Assistant Counselor at SOAR will not have a full case load while an assistnat counselor.
Case load assignments are printed out weekly and adjusted in the event of a staff being assigned a patient knowing one of theirs are being transferred or D/C, and if that does not happen a counselor or assistant counselor may get an overload. Going forward a designated staff member will follow case loads for all Counselors. Counselor Assistants will go before a supervisory board of at least 3 staff before being given a large case load. No assistant counselor will have a full case load until thay become a full counselor. The Clinical Supervisory team and HR Director will be responsible to oversee this plan is in compliance. This plan will be in place after a meeting of the clinical supervisory committee if formed by January 31, 2013. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on the review of supervision notes and employee personnel records, the facility failed to document weekly case reviews with each counselor assistant for the required time period in two of two personnel caseloads. The findings included:Eighteen employee records were reviewed on January 8, 2013. Two of the eighteen personnel records were counselor assistants, #17 and 18. In accordance with the regulations, a counselor assistant with a high school diploma or GED equivalent may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Both employees were employed at this facility in counselor assistant status with high school diploma status during the review period. Employee #17 was hired on August 25, 2011 and promoted to counselor assistant on March 9, 2012. Employee #17 will be under supervision for a year due to only having a high school diploma. The following weeks of documented supervision were missing: April 9th through 13th, April 16th through 20th, April 30 through May 4th, May 21st through May 25th, the months of June, July, August, September, October and November, December 3rd through 7th, December 10th through 14th, December 17th through 21st and January 1st through 4th.Employee #18 was hired August 3, 2012 and will be under supervision for a year due to only having a high school diploma, the bachelor degree did not meet. The following weeks of documented were missing: August 6th through 10th, the month of September, October 1st through 5th, October 15th through 19th, October 22nd through 26th, October 29th through November 2nd, November 5th through 19th, November 19th through 23rd, November 26th through 30th, the month of December and December 30th through January 4th.An interview with the facility director on January 9, 2013 confirmed the findings.
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Plan of Correction
Employee #17 is no longer an assistant counselor at SOAR.
Employee #18 Supervisory notes missing for the employee #18 are from his binder that the supervisor had in her office. SOAR supervisory staff are looking for the notes. This employee was and is under supervision with a lead counselor, as well as a supervisor. His Supervisor is no longer employed at SOAR. The staff who was in his groups and individual sessions state he was doing good work spicifically with the Latino population. We will add supervision time with proper documentation in order to be compliant with the state regulations.
A counselor assistant will be supervised by staff who meet the qualifications in 704.6 or 704.7 for supervision. Documentation of direct observation will include co-signed progress notes, client record of services, and staff schedule. In the event of a counselor assistant being placed and does not meet the qualifications in 704.9 ( c ) will remain a counselor assistant until the requirements are met. Documentation of direct observation will include co-signed progress notes, client record of services, and staff schedule. In the event of a counselor assistant being placed and does not meet the qualifications in 704.9 ( c ) will remain a counselor assistant until the requirements are met. A yearly document to the facility director indication the counselors status shall be completed and in the personal file.
The counselor assistant will meet the requirements for counselor within 5 years of employment.The clinical Supervisors will be responsible for the supervision or a lead counselor if designated. The HR Director will review the supervision notes monthly for compliance.This correction will be in place on or before January 30, 2013.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of administrative documentation, the facility failed to develop an individual training plan in eighteen of eighteen personnel records reviewed.The findings include:Eighteen personnel records were reviewed January 8, 2013. Eighteen personnel were required to have an individual training plan. The administrative documentation reviewed included the policy and procedure manual and personnel records. Per the facility's policy, annual employee training plans would be completed in January of each year. All staff reviewed had a training plan dated January 3, 2013 or January 4, 2013. However, the only training documented on all training plans was the pre-printed annually required training sessions that every employee is required to take. There were no specific training, appropriate to the individual skill levels and needs of each employee, identified in the plan. Facility staff reported the training would be placed on the form after the training was actually taken by the employee making this more of a record of training and not a training plan for the year. An interview with facility staff on January 8, 2013 confirmed the findings.
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Plan of Correction
All staff at SOAR Philadelphia site will have an updated individualized training plan in their folder before 1/31/2013 as per SOAR Policy.
The training plans for each individual clinical and ancillary staff will be placed in the staff folder within the month of January (following SOAR CORP'S policy and procedure manual) of the New Year meeting the requirements of 704.11 Staff development. The preprinted trainings will be for funder and state requirements. The other information on the plan will identify the subject areas and potential resources for training which meet the requirements for the employee's position and which relate to the employees skill level and interest. The staff Managers and Supervisors will be responsible to collect this information from each employee and present it to the HR Director. The HR Director will be responsible to see this information is placed within the month of January of the New Year in the staff files.
This will be completed by 1/31/2013.
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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 counselors in one of four personnel records.The findings include:Eighteen personnel records were reviewed on January 8, 2013. Twelve personnel records pertained to counselors. Four personnel records were required to include documentation of the completion of 25 clock hours of annual training. The facility's training year is from January through December. The facility's 2012 training year was reviewed. The facility failed to document 25 clock hours of annual training in personnel records #8, 9, 10 and 13.Employee # 13 was hired on December 11, 2011. Employee # 13 had only 17.5 clock hours of training documented for the 2012 training year. An interview with the facility director and human resource director on January 9, 2013 confirmed the findings.
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Plan of Correction
The training schedule is for the calendar year not from when an employee starts. Corrections will be made to all staff training for a calendar year starting in 2013. SOAR CORP has an outside trainer approved by the State for PCB approved education. There have been 13 trainings scheduled for the year 2013. All our staff has an opportunity to pick any 6 three hour trainings that staff would like to go to. Some of the Assistant counselors will go to all 13 of the trainings. This will provide the required trainings for outside trainings for clinical staff. The state mandated and payer (CBH, BHSI, Magellan, etc.) will also be offered to all staff. This will be the responsibility of the Clinical Supervisors, as well as the Ancillary Manager to see that their staff meets the yearly requirements. The HR Director will oversee that these training are being done by all staff at the executive weekly meetings.The information will be passed on to the Supervisors and Manager in the next three executive staff meetings starting by January 30, 2013. |