INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 9, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clear Concepts Counseling 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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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.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of HIV/AIDS and TB/STD training in one of five personnel record.The findings include:Six personnel records were reviewed on February 9, 2016. Five personnel records were required to have documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and TB/STD training in personnel record # 6.Employee #6, a counselor, was hired June 25, 2014. HIV/AIDS and TB/STD training was due to be completed no later than June 25, 2015. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of the date of the licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our project will be in full compliance with this standard by 06/30/2016, which is the end of our current training year. By that date employee #6 will have received the required 6 hours of HIV/AIDS and 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training that are DDAP approved. This employee will seek out and attend trainings throughout the year which will address the areas set forth by the standard. In the future, the Project Director will conduct quarterly reviews of all training requirements to ensure that this standard is being complied with. |
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 25 clock hours of annual training in one of one personnel record reviewed.The findings include:Six personnel records were reviewed on February 9, 2016. One out of six personnel records pertained to a counselor and was reviewed for annual training hours. The facility's training year is from July through June. The facility failed to document 25 clock hours of annual training for employee #4 for the July 1, 2014 - June, 2015 training year.Employee # 4, a counselor, was hired in May of 2014. Employee record #4 contained documentation of 14 clock hours of annual training for the July 1, 2014 - June 30, 2015 training year.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard by 06/30/2016, which is the end of our current training year. By that date each employee will have received 25 training hours as is required by the standard. Employee #6 had failed to complete the required trainings. This employee will seek out & attend trainings throughout the year, which will address the areas set forth by the standard. Clinical Supervisor is responsible for ensuring the corrective action(s) is implemented. In the future, the Project Director will conduct quarterly reviews of all training hours to ensure that this standard is being complied with. |
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 a review of client records, the facility failed to obtain informed and voluntary consents in one of eight records reviewed.The finding include:Eight client records were reviewed on February 9, 2016. All were reviewed for informed and voluntary consent forms. The facility failed to document the witness signature and date of that signature, the client's signature and date of their signature on the informed and voluntary consent form for a treatment facility in client record, #7. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard was reviewed during our agency staff meeting on February 18, 2016. The proper completion and documentation of client's signature and date of their signature as well as witness signature and date of their signature on the informed and voluntary consent form for treatment in all client records. To ensure correct completion of consents forms the Clinical Director will verify completion during quarterly reviews. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consents in one of eight records reviewed.The findings include:Eight client records were reviewed on February 9, 2016. All were reviewed for informed and voluntary consent forms. The facility failed to document if the client was offered a copy of the informed and voluntary consent form for a treatment facility in client record, #7. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard was reviewed during our agency staff meeting on February 18, 2016. The proper completion and documentation that the client was offered a copy of the informed and voluntary consent form will begin immediately. To ensure correct completion of consents forms the Clinical Director will verify completion during quarterly reviews. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document a treatment plan update at least every 60 days in two of eight client records reviewed. The findings include: Eight client records requiring documentation of a treatment plan update were reviewed during the renewal inspection on February 16, 2016. The facility failed to document a treatment plan update at least every 60 days in client records, # 6 and 7.Client # 6 was admitted on 6/17/2015 and discharged on 11/11/15. The client's last treatment plan was completed on 6/17/15. Client # 7 was admitted on 6/30/2015 and discharged on 9/30/2015. The client's last treatment plan was completed on 6/30/15.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard were reviewed immediately when it was brought to our attention during the onsite licensure renewal inspection and during our agency staff meeting on February 18, 2016. The individual treatment plan update will be completed at least every 60 days. To ensure completion of treatment plan updates at least every 60 days the Clinical Director will verify completion during quarterly reviews. |