INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 6, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Asociacion De Puertorriquenos En Marcha Proyecto Nueva Vida 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
Based on a review of the Staffing Requirements Facility Summary Report and personnel records the facility failed to ensure that all counselors complete at least 25 clock hours of training annually.
The findings include:
The Staffing Requirements Facility Summary Report and a review of personnel records was conducted on November 6, 2014. The facility failed to document at least 25 clock ours of training for employee #3. Employee #3, a counselor, was employed in that position for the entire training year July 1, 2013 through June 30, 2014. At the time of the inspection there were zero training hours documented for employee #3.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of the inspection, Employee #3 was already scheduled for 40 hours of clinical supervision training, December 8-12, and plans to attend. The employee also completed ten hours of group therapy training by November 11, 2014. S/he is further scheduled to complete an additional ten hours of training by June 30, 2015. The employee will thus catch up with the missed trainings, while also completing this year's training allotment. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection the facility failed to ensure that all fire extinguishers were inspected and approved annually.
The findings include:
A physical plant inspection was conducted on November 6, 2014. The fire extinguishers throughout the facility were tagged with inspection dates of May 2013.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The building's fire extinguishers were inspected and those needing replacement were replaced by November 14, 2014. All building fire extinguishers how show tags of November, 2014. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to display the hours of project operation that can be accessed by the general public.
The findings include:
A physical plant inspection was conducted on November 6, 2014. The facility did not display the hours of project operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Signage has been prepared and the holders ordered to display both the facility's hours of operation, including all of the programs offered, and emergency contact numbers. This will be installed by December 15, 2014. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to display a telephone number that can be accessed by the general public in case of an emergency.
The findings include:
A physical plant inspection was conducted on November 6, 2014. The facility did not display an emergency telephone number.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Signage has been prepared and the holders ordered to display both the facility's hours of operation, including all of the programs offered, and emergency contact numbers. This will be installed by December 15, 2014. |