INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on April 6, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Hispanic American Organization, 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:
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Plan of Correction
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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 the review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training during the facility's January 1, 2019 through December 31, 2019 training year in one of one applicable personnel records.
Employee #6 was hired as a counselor on June 25, 2018. The personnel record documented 23 hours of training.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
a) As of 04/24/2020, HAO D&A Program created a training chart that lists the names of the counselors, to track the yearly mandated education hours required by DDAP's regulations (25 hours). Also, the chart includes the project director and the clinical supervisor required training hours (12 hours). This chart will be review individually, every month, by the project director with each counselor and with the clinical supervisor, always following their individual training plan.
b) Trainings will be in conjunction with the DDAP training schedule as available (online at the present) and will schedule in person trainings when they start to be available again. HAO D&A will also provide the staff with no more than 10 hours a year of in house trainings by the medical director in areas of need.
c) It is the responsibility of the project director to contact the counties and DDAP for dates of available trainings and sites, on monthly basis, either personally, by phone or E-mail.
d) Counselors will be advised during monthly staff meetings by the project director of date, time, place, name of training and other details for each individual's scheduled trainings. The project director will be responsible for the continued monitoring of training to comply with DDAP's mandated trainings requirements.
e) The training chart will be available to all counselors to review if needed.
f) In addition, this specific information will be added to the Staff Development chapter in the Corporate Compliance Plan.
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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on an administrative review, the facility failed to make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders.
The facility provided a copy of the 2019 annual report but failed to verify how they made the report available to the public.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Hispanic American Organization, Inc. will generate an Annual Report within two months of the end of each fiscal year that will list the names of the officers and directors as well as a summary of its activities and financial condition. The distribution of the Annual Report will be posting on HAO website, copies available from Receptionist, and posted in the D&A reception area.
1.The latest copy of the Annual Report will be made available through its website as well as available at the front desk located on the main floor of the building located at 462 W Walnut Street, Allentown, PA 18102. The latest copy will also be posted in the waiting area where the Drug and Alcohol services are provided.
2.A tracking system to ensure future Annual Reports will be available within 60 days of the end of the fiscal year.
3.The D & A Project Director will ensure the Annual report is generated and distributed.
4.The 2019 Annual Report was made available as of April 23,2020 on the website, with copies at the front desk as well as posted in the reception area. The 2019 Annual Report will remain in place until the 2020 Annual Report replaces it.
5.The deficiency is already corrected.
6.The providing and distribution of the Annual Report completely addresses the deficiency.
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