INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12-13, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, New Freedom Recovery Center, LLC 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
The facility failed to document that each counselor completed at least 25 training hours for the 2018 training year.Staff records were reviewed on September 12, 2019. The facility's training year runs January - December and the 2018 training year was reviewed. Counselors #3 and #4 did not have documentation of at least 25 training hours for the 2018 training year.Staff #3 was hired as a counselor on May 2, 2016. There was 10 hours of training documented in staff record #3.Staff #4 was hired as a counselor on July 26, 2016. There was 22 hours of training documented in staff record #4.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9-23-19 the Project Director sent an e-mail to all therapist informing them that their minimum required training hours must be met by year end in accordance with 704.11(f)(2) Licensure Training Hours.
The requirement to meet the minimum training hours will also be communicated to all therapists at staff meetings throughout the year.
The Compliance Coordinator will keep a spreadsheet that will track each therapist's training hours. This information will also be shared with the Project Director and the Clinical Manager. The Project Director and Clinical Manager will monitor and ensure that compliance is obtained by all staff.
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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.
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Observations
The facility failed to limit the information released to an insurance company to what is permitted by PA Code 255.5.Client records were reviewed on September 13, 2019. Client record #2 included a document completed and sent to the insurance company on July 8, 2019 that exceeded what is permitted by PA Code 255.5. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9-23-19 the Project Director met with the Medical Insurance Contact to review the Consent to Release Information to a Client's insurance company in accordance with 709.28 (c) Licensure Confidentiality. The Project Director ensured that the only information released to an insurance company will be what is permitted by PA Code 255.5
The Project Director will monitor compliance through the monitoring of charts during chart review, beginning September 23, 2019.
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