INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 19, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, T. W. Ponessa and Associates Counseling Services, 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 and a plan of correction is due on September 10, 2009.
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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 ensure and document that the project director and facility director completed at least 12 hours of training for the training year 2008 in one of one two records reviewed.
Findings:
Five personnel records were reviewed on August 17, 2009. Two personnel records were required to have at least twelve hours of annual training documented for the facility's 2008 training year. Only 10.5 hours of annual training was documented in personnel record #1.
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Plan of Correction
Project Director will take responsibility to ensure 12 hours of annual training are secured by administrative staff & that the trainings are appropriately documented in the personnel charts.
The Project Director will review the administrative training status will be conducted in the administrative weekly supervision.
The quarterly report written by the Facility Director contains administrative training information & will continue to be utlized as a monitoring instrument. The Project Director will sign-off on the quarterly reports.
Presently, 14 hours of training are documented in personnel record #1 for the 2009 training year. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection conducted on August 19, 2009, the facility failed to ensure that the hours of operation were displayed conspicuously to the general public.
Findings:
During the physical plant inspection on August 19, 2009 the facility did not have the hours of operation posted for the general public.
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Plan of Correction
The hours of operation were posted on August 19, 2009 immediately upon recieving the information that said sign could not be located.
Effective September 1, 2009, the Facility Director will meet bi-monthly with the support staff Coordinator to review the "Required by Law" list of signs that are to be posted. The Facility Director & support staff coordinator will take random sign-checks to ensure all signs are posted. Meeting minutes will be maintained. Facility Director will update Project Director of status of the required posted signs. Project Director will intervine as needed. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection conducted on August 19, 2009, the facility failed to display a phone number conspicuously to the general public for emergency purposes.
Findings:
During the physical plant inspection on August 19, 2009 the facility failed to display an emergency phone number for the general public.
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Plan of Correction
The emergency phone number was conspicuously displayed for the general public on August 19, 2009 immediately upon recieving the information that said phone number could not be located.
Effective September 1, 2009, the Facility Director will meet bi-monthly with the support staff Coordinator to review the "Required by Law" list of signs that are to be posted. The Facility Director & support staff coordinator will take random sign-checks to ensure all signs are posted. Meeting minutes will be maintained. Facility Director will update Project Director of status of the required posted signs. Project Director will intervine as needed. |