INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 7, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northwestern Human Services of Delaware County 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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704.5(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 a personnel record, the facility failed to ensure the project director and facility director met the qualifications for the positions of project director and facility director in one of one personnel record reviewed.
The findings include:
One personnel record was reviewed for documentation of the qualifications for the positions of project director and facility director. The facility failed to ensure that employee # 1 met the experiential qualifications for the positions of project director and facility director.
Employee # 1 was hired as the project director and facility director on May 12, 2014. Employee # 1 has a qualifying Master's Degree with a qualifying major and over 4 years of direct service experience. However, based on employee # 1's resume, employee # 1 did not have 2 years of experience in a human service agency which includes supervision of others and program planning.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An exception will be filed to allow current project/facility director to remain in the position based on management experience in other work areas that correlates to the management skills required for the project/facility director role. Employee #1 has received continual supervision from executive director. If the exception is denied, then current Executive Director, will be the designated project/facility director. Additionally, the Executive Director will make sure that any new hired project director/facility director meets the qualifications for the position of project director/facility director. |
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
Based on a review of the facility's Staffing Requirements Facility Summary Report (SRFSR), the facility failed to ensure that all personnel received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training, using a Department approved curriculum, within the regulatory time frames.
The findings include:
The facility's SRFSR form, completed by the facility, was reviewed during the licensing process. The facility failed to ensure that employee # 7 completed HIV/AIDS and TB/STD trainings within the regulatory time frames.
Employee # 7 was hired as a Front Desk Scheduler on October 22, 2007. HIV/AIDS and TB/STD trainings were due to be completed no later than October 22, 2009. However, employee # 7 was not listed on the SRFSR form as having completed HIV/AIDS and TB/STD training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #7 will attend required training for HIV/AIDS on 6/2/2015 as this is the next available training in her vicinity. The Program Director will continue to search for other available trainings for a closer date. Employee #7 attended required training for TB/STD on 9/24/2009. Employee will submit completion certificate to Program Director. The Program Director will be responsible for making sure that employee # 7 completes HIV/AIDS training. Moving forward, Program Director, will be responsible for ensuring that all employees receive a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training, using a Department approved curriculum, within the regulatory time frames.
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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 a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of annual training in one of two personnel records reviewed.
The findings include:
On January 7, 2015, two personnel records requiring documentation of 25 clock hours of annual training were reviewed. The facility failed to provide documentation of 25 clock hours of annual training in personnel record # 6.
Employee # 6 is a counselor and was hired October 1, 2007. Employee # 6 was required to complete 25 clock hours of annual training hours by June 30, 2014. However, personnel record # 6 only had documentation of 6.5 clock hours of annual training for the July 1, 2013 to June 30, 2014 training year as of January 7, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #6 was advised in supervision about the deficiency. Employee #6 was re-trained on January 20th on training requirements. Monthly review of attended trainings will be conducted to ensure adherence to requirement. Employee #6 will submit completion certificates to Program Director. Additionally, the Program Director will make sure that employee # 6 and all other counselors complete 25 hours of annual training every year. |