INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 6, 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, Centre Counseling Associates 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
During a licensing inspection conducted on December 6, 2019, the facility failed to provide documentation of at least twenty-five clock hours of training annually for employee # 1.
Employee # 1 personnel record showed zero training hours for 2017 and only 16 training hours for 2018. Employee #1 is required to complete at least 25 clock hours of training annually.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director acknowledges his mistake and will within 90 days complete the requirement of 25 hours of CEU's in the appropriate categories. The Project Director shall more carefully check his progress in achieving compliance in this area. |
709.28 (c) (6) 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. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
During a licensing inspection conducted on December 6, 2019, the facility had an informed and voluntary consent to disclose form that had expired in client record # 1.
Client # 1 was admitted on December 15, 2010 and was still an active client at the time of the inspection. An informed and voluntary consent to disclose form to a "clinic" expired on December 15, 2011.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director shall review all current clients for any required updates. He will work with each client to facilitate the timely review and compliance with any deadlines and or revisions. This shall be done initially within 60 days and periodically on a timely basis. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
During a licensing inspection conducted on December 6, 2019, the facility failed to provide documentation of the clients being notified of their rights in one of one record reviewed.
Client # 1 was admitted on December 15, 2010 and was still active at the time of the inspection. There was no written acknowledgement in the client file that they had been notified on client rights.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Within 60 days or at the next scheduled session the counselor shall review these issues with the client and place a signed document of compliance within the appropriate file. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
During a licensing inspection conducted on December 6, 2019, the facility failed to provide documentation of a client orientation to include project policies, hours of operation, fee schedule, and services provided in one of one record reviewed.
Client # 1 was admitted on December 15, 2010 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A written documentation is administered to the client upon his intake. The written document was available but there was no documentation in the client's file of these explanations. The Project Director will create a form and have it reviewed and signed by each client at intake. This shall be completed within 60 days. |