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 May 7, 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, Colonial House Outpatient 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of one of one counselor assistant personnel records, the facility failed to provide documentation of at least one hour of direct observation per week for the months of February and March 2020 and the weeks of April 5-11, 12-18, and 19-23, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Operations will review and discuss the expectations associated with Counselor Assistant's with agency supervisor to ensure compliance of supervision in direct and close observations periods.
In addition, Director of Operations will review clinical supervision notes on a quarterly basis for all clinical staff. |
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 the review of eight personnel records, the facility failed to provide documentation of 12 training hours as required for employee # 2.
Employee # 2 was hired as the Facility Director on March 27, 2014 and was still in this position at the time of the inspection. A review of personnel records documented only 9 of the 12 required training hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Operations will monitor employee training hours on a quarterly basis to ensure annual compliance associated with required training hours. The quarterly reviews will take place every three months, starting with 06/2020 to correct an error regarding hours for CPR/First Aid in all training folders; All employee training certificates be submitted to the Director of Operations for compliance monitoring purposes. These certificates will be maintained and hours will be tallied in the employee training record. |
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 eight personnel records, the facility failed to provide documentation of 25 training hours as required for employee # 7.
Employee # 7 was hired as a counselor on January 9, 2017 and was still in this position at the time of the inspection. A review of personnel records documented only 3 of the 25 required training hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Operations will monitor employee training hours on a quarterly basis to ensure annual compliance associated with required training hours. The quarterly reviews will take place every three months, starting with 06/2020 to correct an error regarding hours for CPR/First Aid in all training folders; All employee training certificates be submitted to the Director of Operations for compliance monitoring purposes. These certificates will be maintained and hours will be tallied in the employee training record. |