INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 1 & 2, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on May 25, 2007.
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Plan of Correction
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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
The program failed to document an individual training plan for personnel record #1.
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Plan of Correction
1) Due to a change in supervisors this training plan was neglected.
2)This standard was brought into compliance by develping a training plan on May 2, 2007.
3) The training plan was documented and signed by the Division Director and the Program Director on May 2, 2007. |
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
The program failed to provide documentation of the required HIV/AIDS and TB/STD training for personnel record #4.
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Plan of Correction
1)This part time therapist did not meet the training requirement for HIV/AIDS and tuberculosis and STDs within two years because of schedule conflicts with her full time job and the limited availability of approved training in the Erie area.
2)The project will be in compliance by June 30, 2007.
3) Staff who have not met the requirement will be provided training at Gateway Rehabilitation Center Main Campus in Aliquippa, PA during the month of June 2007. |
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
The program failed to document the required 25 hours of training for the previous training year for personnel record #7.
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Plan of Correction
1) The therapist had training hours from another facility that were not included in our data. Some of our data was not sent to Human Resources Still, we have not met the standard, as our records indicate only 23.5 hours of training.
2) The staff member will bring in the additional certification of training hours collectively his certificates to Human Resources.
3) Target date for reconciling this standard in June 1, 2007. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
The facility failed to have one full time equivalent (FTE) counselor for every eight clients in the Phase II work release program. The facility does have an exception for one FTE counselor for every ten clients, but the ratio at the time of the survey is 1 to 14.
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Plan of Correction
1) Our contention has been that Case Management functions are indeed part of the therapeutic staff. The Department, however, does not recognise the legitimacy of this arguement. I argue that I have designated two staff members to develop expertise in Case Management their role had formerly been a function of the Counselors because of the nature of our business, it makes sense to develop expertise in the Case Managment arena.
Despite my stance, the Department had made this a regulatory issue for the past three years at this juncture, it seems futile to consider my point of view justifiable. As a result, we will change the job stated of Case Managers to Counselors. The Case Managers will incorporate traditional counseling functions of providing group therapy and individual treatment into their job repertoire.
2) Because of the change in job descriptions this standard will be in compliance by August 1, 2007.
3) We will change job descriptions of Case Managers to Counselors. They will develop clinical expertise under the supervision of the Program Director over the next year. The Staff members have already met the requirement for Counselors by having a degree and a clinical background accepted by the Department. |
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
The program failed to provide an informed consent for for the release of information in client records # 1 through 5. The purpose section and the specific information section is not adequately completed on those release of information forms.
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Plan of Correction
1) Staff members who completed consents were not following the guidelines for the standard this appears to be a training and supervision issue.
2) The standard will be in compliance by June 30, 2007.
3) On May 16, 2007 a memo was drafted to the security staff by the Custody and Control Coordinator indicating what needed to be corrected.
Clinical staff was directed to periodically check the releases to insure compliance. Deficiencies are to be brought to the attention of the Program Director. The Program Director will establish a training if necessary. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
The program failed to document the inspection of storage areas for November 2006 and December 2006.
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Plan of Correction
1) During the last year we changed our procurement of medication to a regional pharmacy. Their documentation of medication dispensing did not meet our policy or department requirements.
Our former procedure did meet both policy and department requirments.
As a consequence of this inspection we are returning to our former procedure.
2) This procedure will be in place by May 25, 2007.
3) In a staff meeting on May 16, 2007, we discussed the merits of fixing the problem or returning to a familiar procedure. We set a deadline with managers and staff to return to the former procedure by May 25, 2007. |