INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 27, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Spring-Ford Counseling Services 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.
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure that all counselors completed at least 25 clock hours of annual training in one of one personnel records reviewed.
Employee # 1's personnel record documented 15.75 hours of annual training for the facility's previous training year reviewed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Within 30 days, Director will meet with staff to remind of training hours are 25 hours per fiscal year for all counselors who work with Drug/Alcohol clients. Director will review training hours 2x per year to verify 25 hours are being met. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of client records, the facility failed to document that treatment and rehabilitation plans were reviewed and updated at least every 60 days in one of two client records reviewed.
Client #1 was admitted on December 29, 2020 and was discharged July 7, 2021. A treatment plan update was completed on March 19, 2021 and the next update was due no later than May 19, 2021. However, the update was not completed prior to the client's discharge from the program.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
As of 11/5/21 the Executive Director has informed all treatment providers the requirements of Treatment Plan updates, every 60 days. Executive Director will continue to review charts to ensure timeliness of required paperwork. |