INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 13, 2016 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, Alternative Counseling Associates, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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
Based on a review of the personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of four employee records reviewed.
Employee #3 was hired as a counselor on March 1, 1999 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from October 1, 2014 through September 30, 2015. The personnel record for employee #3 only included documentation of 3 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
Each counselor will be responsible for ensuring that they are in compliance with 704.11 Licensure Training Hours, and Staff development. To ensure that this does not occur in the future, each counselor's 25 hour mandatory training hours per training year will be reviewed by the Executive Director and/ or the Administration Assistant every six months to ensure that the trainings are being pursued and completed in a timely manner and that the 25 hours are completed by each counselor within the October 1- September 30 training year. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, conducted on September 13, 2016 at approximately 11:00 am, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times, as the female client bathroom in the basement floor apartment on the 438 side of the facility was observed to have mold growing in multiple locations on the ceiling.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director take full responsibility for this citation. The bathroom located on the basement floor of 438 side of the facility will have additional and more effective duct work installed by maintenance personnel to eliminate mold.Additionally the mold infected will be bleached and cleaned to remove the existing mold. Supervision of the project will be by the Executive Director. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the November 2015 through August 2016 fire drill logs, the facility failed to ensure that an unannounced fire drill was conducted during sleeping hours at least once every 6 months. There was an overnight drill conducted in January 2016 and then another one in July 2016, which was 7 months apart.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The maintenance department, under the supervision of the Executive Director, will ensure that two unannounced fire drills will be completed during the third shift hours not more than six months apart. They will be appropriately logged and reviewed monthly by the maintenance personnel and the Executive Director. this will be completed 9/20/2016 |
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.
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Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in client record #4. Client #4 was admitted on 07/06/2016 and was still an active client at the time of the inspection. There was documentation of facsimiles sent to a district court on 07/07/16 and an attorney ' s office on 07/07/16 and 08/22/16; however, there was no proper consent to release information forms signed by the client prior to disclosure for either agency. Additionally, client record #4 had a consent to release form to a government agency that did not include the specific information to be released and the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
I the Executive Director take full responsibility for this citation.
To ensure that this does not occur in the future, each counselor will be responsible for ensuring that they are in compliance with proper confidential release of information forms filled out in the entirely including specific reasons for the consent.The client active file was addressed by having the client sign and date a new entirely completed consent and submitted to her file. No consent will be submitted to a file unless there is a specific person/facility entered into the consent as well as a signature by the client. Random chart inspections will be conducted by the Executive Director and the counselor during supervision meetings to further ensure compliance. |