INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from November 5, 2011 to November 6, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site survey, Northwestern Human Services of PA, Susquehanna Center 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 the inspection.
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Plan of Correction
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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 staff development records the facility failed to document HIV/AIDS and TB/STD training in one of three personnel and staff development records.
Findings :
Five staff development records were reviewed on October 5, 2011 and October 6, 2011 Three records were reviewed for documentation of HIV/AIDS and TB/STD training. One of three records failed to document the required training.
Employee # 1 is a counselor and was hired on December 7, 2009. HIV/AIDS and TB/STD training was due to be completed no later than December 7, 2010. Documentation of required training was not available at the time of the review on October 5, 2011 and October 6, 2011.
The facility director was interviewed on October 5, 2011 and confirmed the findings.
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Plan of Correction
In addition to providing staff with a copy of their annual training plan which includes HIV/AIDS and TB/STD trainings when applicable, the Program Director will conduct a monthly audit of the trainings that staff have completed and what still remains for them to complete. This information will then be reviewed with all employees during the monthly staff meeting. If any of the staff members are not able to attend the regularly scheduled meeting they will be given a copy of the meeting notes which will include their training information. The monthly audit and the audit review will begin with our staff meeting that is scheduled for December 7, 2011 and will continue through each training year. The staff training review will be recorded in the meeting notes and these notes will be available for review by the DOH upon request. |
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 staff development records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of two personnel and staff development records.
Findings:
Five staff development records were reviewed on October 5, 2011 and October 6, 2011. Two records were for counselors. One personnel record was required to document the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record 3.
Employee # 3 was hired on July 12, 2010 The facility training year is from July through June annually. The training year for July 2010 to June 2011 was reviewed. Employee # 3 completed 15 hours of annual training for the 2010/2011 training year.
The facility director confirmed on October 5, 2009 that the counselor did not have the 25 clock hours of training for the 2010/2011 training year.
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Plan of Correction
In addition to providing staff with a copy of their annual training plan which includes HIV/AIDS and TB/STD trainings when applicable, the Program Director will conduct a monthly audit of the trainings that staff have completed and what still remains for them to complete. This information will then be reviewed with all employees during the monthly staff meeting. If any of the staff members are not able to attend the regularly scheduled meeting they will be given a copy of the meeting notes which will include their training information. The monthly audit and the audit review will begin with our staff meeting that is scheduled for December 7, 2011 and will continue through each training year. The staff training review will be recorded in the meeting notes and these notes will be available for review by the DOH upon request. |