INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 22, 2009 and September 24, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital Outpatient Treatment Program 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 and a plan of correction is due on October 23, 2009.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the staffing requirements facility summary report, personnel records, census reports, staff development records and interviews of the project and facility director, the project failed to employ a full-time clinical supervisor for eight full-time counselors.
Findings:
A review of the staffing requirements summary report on September 24, 2009 revealed documentation of 7.6 full time counselors for the outpatient activity and one full time counselor for the detoxification activity for a total of 8.6 full time counselors. The census report reviewed on September 24, 2009 documented the clinical supervisor with a case assignment of 20 clients. A review of the staffing summary report and the clinical supervisors personnel file provided documentation that the clinical supervisor is also responsible for administrative responsibilities as the defined facility director. The facility did not have a full time clinical supervisor.
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Plan of Correction
Clinical Supervisor will resume clinical supervision responsibilities as of 10/01/09 when a new outpatient bilingual counselor will start and assume caseload. |
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 staffing requirements facility summary report, staff development records, staff development procedures and interviews with project staff, the facility failed to provide or document 25 hours of training for each counselor.
Findings:
Two of five counselors listed on the staffing requirements facility summary report reviewed on September 22, 2009 were required to obtain 25 hours of training for the 2008 calender year. A review of the two staff development records on September 24, 2009 failed to provide documentation of 25 hours of training for 2008 in two of the two records reviewed.
Employee # 4. Counselor hired on January 27, 2007. Staff development program requires 25 hours of training for the 2008 calender year. A review of employee #4 on September 24, 2009 revealed documentation of 18.5 hours of training for year 2008.
Employee # 5. Counselor hired on January 8, 2007. Staff development program requires 25 hours of training for the 2008 calender year. A review of employee # 5 on September 24, 2009 revealed documentation of 3.5 hours of training for year 2008.
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Plan of Correction
Clinical Supervisor provided all staff with an in-service on DOH Annual Training Hours and reminded staff they are to take responsibility in intialating a minimum of 10 hours on their own and hospital will provide them with the remaining mandated hours. Clinical supervisor will do quaterly review of training hours and send out appropriate notices to staff allowing them time to get hours in. First review to be comleted by 09/30/09. |