INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the August 10, 2011 licensure renewal inspection. The follow-up inspection was conducted on May 11, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Innovative Recovery Services 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
Compliance with this regulation could not be determined during the plan of correction follow up inspection. Compliance will be determined during the next scheduled inspection. The original deficiency is listed below:
Based on a review of personnel records, the staffing requirements facility summary report and an interview with the project/facility director, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one personnel records.
The findings include:
Two personnel records were reviewed on August 9, 2011. Two personnel records pertained to employees performing counselor duties. One personnel record required documentation of 25 clock hours of annual training. The other personnel record pertained to a new counselor who was hired after the completion of the 2010 training year. The facility failed to document 25 clock hours of annual training in personnel record # 1.
Employee # 1 was hired on September 21, 2009. Employee # 1 is the project/facility director. Employee # 1 is also the primary counselor for the facility. Per the staffing requirements facility summary report; employee # 1 provided 30 clinical hours per week to a caseload of 22 clients. The facility training year is from January through December. Employee # 1 only completed 9 clock hours of annual training from January 2010 through December 2010. Employee # 1 failed to document 25 clock hours of annual training from January 2010 through December 2010, at the time of the review, on August 9 - 10, 2011.
Employee # 1 was interviewed on August 9, 2011 at approximately 2:45 PM and confirmed the findings.
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Plan of Correction
Facility Director will monitor staff training to ensure that each individual receives the required number of training hours annually. Facility Director will assist with registration as needed and will offer information regarding trainings as it is obtained. Facility Director will immediately begin to track training hours to ensure compliance. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
An exception request has been approved by the Department. However, compliance with this regulation could not be determined during the plan of correction follow up inspection. Compliance will be determined during the next scheduled inspection. The original deficiency is listed below:
Based on a review of administrative materials and an interview with the project/facility director, the project failed to complete the 2010 audit by the end of the project's fiscal year, as required by regulation.
The findings include:
A review of administrative materials was conducted on August 9, 2011. Per regulation, the project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services. The project's fiscal year is from January through December. The project failed to document the completion of an annual audit for the January through December 2010 fiscal year, at the time of the review, on August 9 - 10, 2011.
On August 9, 2011 at approximately 2:45 PM, the project/facility director confirmed an annual audit has not been completed for the 2010 fiscal year. The project/facility director reported the project is in the process of requesting an exception from the Department.
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Plan of Correction
Facility Director will submit all required documentation to request an exception as defined in Licensing Alert 01-11 ? Financial Audits. The required information was submitted and an exception is maintained on file by the Facility Director. |