INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 4, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Butler Regional Recovery Day Program 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 5, 2008.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of the project director's personnel record on August 4, 2008, the facility failed to document that the project director met the qualification requirements for that position.
Finding:
The project director's qualifications were not documented in the personnel record presented for review at the time of the inspection.
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Plan of Correction
Project Director's personal file will be updated to include degrees, certifications, and work experience. This plan will be completed by 10/15/08. The facility director working in conjunction with the human resources department will be responsible. |
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
Based on the review of six personnel records on August 4, 2008, the facility failed to document a written individual training plan in one of six personnel records.
Finding:
The individual training plan was missing from personnel record # 1.
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Plan of Correction
The missing education plan will be completed by 10/15/08. In the future,all education plans will be completed by July 1st of each fiscal year. The facility director will be responsibile. |