INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 20, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHD - Womanspace 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 personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project directors and facility directors during the training years reviewed.
Employee # 1 was hired as the Project Director on February 18, 2018. The personnel record documented 0 hours of annual training during the facility's July 1, 2019 through June 30, 2020 annual training year.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Employee #1 will obtain 12 hours of training in required areas by 6/30/22 and in all subsequent training years to meet the standard. This will be monitored by the RHD CEO who is her direct supervisor with additional review with Service Line Director for Drug and Alcohol Programs quarterly to ensure that the standard is met. |
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 during the training years reviewed.
Employee # 3 was hired as a counselor on August 4, 2013. The personnel record documented 24 hours of annual training during the facility's July 1, 2020 through June 30, 2021 annual training year.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Employee #3 will obtain 25 training hours to meet the standard by 06/30/2022.
Facility Director and Assistant Director will monitor training hours throughout the year through quarterly review of personnel charts and review training hours and needs during monthly supervision. |