INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection of Berks Counseling Center, Inc. conducted on March 21st and 22nd, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Berks Counseling Center, 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:
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Plan of Correction
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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.
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Observations
Based on a review of client records, record #'s 1, 5, and 6 had treatment plan updates completed after the regulatory timeframe or missing at the time of the inspection.Client #1 was admitted 1/4/2017 and was an active patient at time of inspection. A treatment plan update was completed 1/4/2017 and the next update was due no later than 3/4/2017; however, the update was not completed at the time of the inspection.Client #5 was admitted on 8/8/2016 and was discharged on 11/2/2016. A treatment plan update was completed 8/17/2016 and the next update was due no later than 10/17/2016. However, the update was not completed at the time of the inspection.Client #6 was admitted on 8/11/2016 and discharged on 1/26/2017. A treatment plan update was completed 10/3/2016 and the next update was due no later than 12/3/2016. However, the plan update was not completed until 1/3/2017.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisors have conducted a training in February 2017 on completing treatment plans and treatment plan updates. This training includes timeframes for completing treatment plans and treatment plan updates. All clinical staff were required to attend this training. Supervisors will do individual training with any staff who were not in attendance and with any new staff. Training will be completed by the end of April 2017 for staff who missed the training. For new staff, this will be completed within the first month of employment. As part of our ongoing Compliance Plan, clinical supervisors review 10 patient charts per month. Reviewing treatment plans and treatment plan updates is part of this review.
We have already instituted the following in order to ensure timely completion. The treatment plan is required to be completed at the first session with the therapist after intake. At the end of that session, a 30 minute treatment plan update session is scheduled 1 to 2 weeks prior to the actual due date. The session is marked in a different color in the therapist's schedule and updating the treatment plan is the sole reason for the session. The therapist explains the importance of attending that session to the patient in order to continue with services. If a patient misses that session, the therapist attempts to schedule the patient in the same week. If the patient can't be scheduled with their primary therapist, the therapist notifies the clinical supervisor, who will schedule the patient with another therapist to complete the treatment plan update. If a therapist is out on the day a patient's treatment plan update is due, clinical supervisors may schedule the patient with another therapist. If the patient is unable to be scheduled or misses the rescheduled session, an alert is entered into the EHR that the patient cannot receive any services until he/she meets with a therapist to complete the treatment plan update. |
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 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #3 and #9 received the minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.Employee #3 was hired as a clinical supervisor on 02/28/2011 and was due to have the communicable disease trainings no later than 02/28/2012. There was documentation in the personnel file of only having completed 3 hours of the required 6 hours of HIV/AIDS training as of the date of the inspection.Employee #6 was hired as a counselor on 1/26/2015 and was due to have the TB/STD trainings no later than 1/26/2016. There was no documentation in the personnel file of the completion of TB/STD training as of the date of the inspection.Employee #16 was hired as a medical assistant on 07/07/2014 and was due to have HIV/AIDS and TB/STD trainings no later than 07/07/2016. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.Employee #17 was hired as a certified medical assistant on 07/21/2014 and was due to have the HIV/AIDS and TB/STD trainings no later than 07/21/2016. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.Employee #18 was hired as a clinical care coordinator on 08/10/2010 and was due to have the HIV/AIDS and TB/STD trainings no later than 08/10/2012. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Most of the mandatory communicable disease training is completed in-house and includes 6 hours of HIV/Aids and 4 hours of TB/STD. We discovered that in the past, one of the trainings that was scheduled did not meet the required hours. Clinical Director of Drug and Alcohol Services will work with the medical department trainer to ensure that the trainings are compliant with regulations. Clinical director will look for potential on-line trainings and submit them for approval by DDAP in order to ensure that staff who don't have the required number of hours have other trainings available by the end of June 2017. Clinical director will identify staff needing the mandatory training and will communicate requirements to all supervisory staff by the end of April 2017. Supervisory staff will be responsible to ensure that all of their staff members complete this training within the first 2 years of employment. Clinical supervisors will ensure that all of their staff members complete this training within the first year of employment. Certificates for completion will be given to Human Resources who will scan them into Relias Training Management System. Clinical director will review the training records quarterly for compliance. |
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 records, the facility failed to document the completion of 25 clock hours of annual training required for employee #6.Employee #6 was hired as a lead counselor on 1/20/2015 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from 07/01/2015 through 06/30/2016. The personnel record for employee #6 only included documentation of 21.25 hours of annual training for the training year reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisors will review training records for all their staff by the end of January each year to ensure staff are on track to complete 25 hours of training for the fiscal year. For any staff who have not completed the required number of hours, supervisors will work with those staff to complete assigned trainings. Clinical Director of Drug and Alcohol Services will review all clinical staff trainings quarterly to ensure compliance. To ensure compliance for the 2016-2017 training year, clinical supervisors will review staff records by the end of April and work with staff who need additional training hours by June 30, 2017. |