INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 17, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Glenbeigh Center of Erie 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 a review of the personnel training records, the facility failed to have the counselor complete at least 25 clock hours of annual training in one of five records.
Employee #3 was hired as a counselor on March 15, 2022. Employee #3 documented 0 hours of training for the July 1, 2023 to June 30, 2024 training year
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director shall monitor training progress of all employees quarterly to ensure that all counselors, no matter what their hiring status, are on pace to complete the required 25 hours of training per calendar training year in the allotted time. Any counselor that is not on pace to complete the required 25 hours of training when monitored shall be required to present a written plan to the project director detailing a plan to complete the training in the time required. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure the FTE counselor caseload in outpatient programs did not exceed 35 active clients for one of five counselors reviewed.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee #5 was hired as a counselor on December 4, 2018. The employee's ratio calculation was as follows: 10/40= 0.25 (FTE); 18/0.25 = 72, which equals a client/counselor FTE ratio of 72:1.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Prn Employee #5's caseload shall be distributed to the project director's caseload ensuring that employee # 5 does not carry a caseload that exceeds 10 clients. To ensure this does not happen in the future caseloads shall be monitored by project director. A new position was generated and is looking to be filled to ensure lower caseloads in future, with the project director absorbing any clients over 10 until the new position is filled. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative information, the project director failed to prepare, annually update, and sign a written manual delineating project policies and procedures for the year 2023.
The last written sign off was documented on July 26, 2019.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The written manual, which is prepared and updated annually, shall be documented as such by the project director signing off in the front of the manual stating that the manual was prepared and updated. This shall be done yearly stating if there are any or no changes to the manual, and initialed and dated by the project director. |