INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 30, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on May 19, 2006.
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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
There was no documentation to show that one employee did obtain the mandatory HIV/AIDS and STD/TB training.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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
Two employees did not obtain 25 hours of training for the previous training year.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.28(c) 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 shall be in writing and include, but not be limited to:
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Observations
In client charts #6 and #4 the "other" box was designated as the purpose for the release of information, but no reason was listed in the line beside the box. In chart #2 the PCPC exceeded the restrictions imposed at 4 Pa. Code subsection 255.5(b) with legal information. In chart #1 a parent line was included on a form. The above listed reasons make the consent forms involuntary and uninformed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.31(a) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(a) If a project utilizes Department funds, it shall comply with the Department's UDCS.
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Observations
The record retrieval process during the licensing inspection was inefficient. Agency policy regarding storage of closed records at the main site was not consistently followed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |