INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 2, 2012 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site inspection, Family Service Association of Bucks County 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(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 the Staffing Requirements Facility Summary Report and an interview with the facility director, the facility failed to ensure that staff persons and volunteers received 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.
The findings include:
On February 2, 2012 the Staffing Requirements Facility Summary Report which was complete by the facility on January 30, 2012 was reviewed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training. The facility failed to provide documentation of the required 4 hours of TB/STD training in two of eighteen records, specifically # 12 and 13.
Employee # 12, a counselor hired on 2/9/10 was due to complete 6 hours of HIV/AIDS and 4 hours of TB/STD training no later than 2/9/11.
Based on a review of the Staffing Requirements Facility Summary Report employee # 12 failed to complete 4 hours of TB/STD training.
Employee # 13, a counselor hired on 7/3/10 was due to complete 6 hours of HIV/AIDS and 4 hours of TB/STD training no later than 7/3/11.
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Based on a review of the Staffing Requirements Facility Summary Report employee # 13 failed to complete 4 hours of TB/STD training.
The facility director was interviewed on February 2, 2012 and confirmed the findings.
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Plan of Correction
The Director of Clinical Servicers (DCS) has scheduled an on-site 4-hour TB/STD training to on March 26, 2012. The DCS has notified staff members #12 and #13 that they are out of compliance with Drug and Alcohol licensure staffing requirements and that their attendance at the March 26 training is mandatory.
During the first week in January of each year, Family Service Association of Bucks County (FSA) provides an on-site 4-hour TB/STD training to ensure that all staff members meet this staffing requirement. In keeping with this training schedule, FSA will schedule a mandatory TB/STD no later than January 4, 2013.
To better ensure consistent, ongoing staff compliance with Drug and Alcohol training requirements, FSA has developed a database to track staff training; provide supervisors with quarterly training reports; and notify supervisors when a staff member is out or potentially out of compliance with Drug and Alcohol training requirements. This will allow supervisors to track both training hours and type of trainings, i.e. mandatory trainings, trainings provided by facility staff, and trainings provided by outside trainers.
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704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR), an interview with the facility director and a review of personnel training records, the facility failed to ensure that at least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
The findings include:
The SRFSR complete by the facility on January 30, 2012, reviewed on February 2, 2012 identified 13 staff that were required to complete the mandatory number of training hours based upon their position, employee #1 - project director, employee #2 - facility director and nine counselors.
The facility failed to ensure that two out of 13 staff completed at least 50% of their training hours with trainers not directly employed by the project.
Based on the SRFSR, employee #21 with a hire date of 4/13/2000 only completed 5 of the 26.5 completed hours of training with trainers not directly employed by the project.
Based on the SRFSR, employee #22 with a hire date of 5/2/2007 only completed 3 of the 27 completed hours of training with trainers not directly employed by the project.
The facility director was interviewed on February 2, 2012 and confirmed the findings.
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Plan of Correction
Family Service Association of Bucks County (FSA) will ensure that at least half of the trainings in its 2012-2013 Staff Development Training Schedule are provided by outside trainers. FSA will engage outside speakers to provide trainings on some selected topics identified by staff in the annual Staff Training Needs Assessment, conducted in April of each year. To further facilitate staff access to outside trainings, FSA has contracted with Essential Learning which offers a broad range of web-based trainings. FSA has developed a list of required Essential Learning trainings; staff may also chose additional Essential Learning webinars, based upon their own individual training needs. When developing annual individualized Educational Plans with staff members, supervisors will ensure that at least 50% of the required 25 training hours are by outside trainers.
To better ensure consistent, ongoing staff compliance with Drug and Alcohol licensure training requirements, FSA has developed a database to track staff training; provide supervisors with quarterly training reports; and notify supervisors when a staff member is out or potentially out of compliance with Drug and Alcohol training requirements. This will allow supervisors to track both training hours and type of trainings, i.e. mandatory trainings, trainings provided by facility staff, and trainings provided by outside trainers.
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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 (SRFSR), an interview with the facility director and a review of personnel training records, the facility failed to ensure that each counselor completed at least 25 clock hours of annual training.
The findings include:
The SRFSR complete by the facility on January 30, 2012, reviewed on February 2, 2012 identified nine counselors that were required to complete 25 hours of training for the training year. The facility failed to ensure that one out of nine counselors completed the require 25 hours of training, specifically, employee #11.
Based on the SRFSR, employee #11 with a hire date of 7/24/2007, only was listed as having completed 23 of the required 25 hours of training.
The facility director was interviewed on February 2, 2012 and confirmed the findings.
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Plan of Correction
The assigned supervisor met with staff member #11 and reviewed the D&A licensure requirement that all staff obtain 25 hours of training annually. The assigned supervisor will monitor the training hours of staff member #11 during the remainder of the current Staff Development Year (7/1/11 ? 6/30/12) and in the upcoming year (7/1/12 ? 6/30/13) to ensure ongoing compliance with this staffing requirement. At a staff meeting held on February 21, 2012 the Director of Clinical Services (DCS) reviewed the 25-hour Drug and Alcohol training requirement with all staff.
To better ensure consistent, ongoing staff compliance with Drug and Alcohol training requirements, FSA has developed a database to track staff training; provide supervisors with quarterly training reports; and notify supervisors when a staff member is out or potentially out of compliance with Drug and Alcohol training requirements. This will allow supervisors to track both training hours and type of trainings, i.e. mandatory trainings, trainings provided by facility staff, and trainings provided by outside trainers.
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709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records and a review of the facility's policy and procedures manual, the facility failed to document case consultation notes in accordance with facility policy and procedures.
The findings include:
Facility policy titled Case Consultation - States: Treatment Team reviews open cases every 90 days. The Case Consultation, completed by the assigned Clinician, summarizes team discussions and recommendations for each client. The supervisor and psychiatrist sign and date the form.
On February 2, 2012 seven client records requiring documentation of case consultations were reviewed. The facility failed to document a case consult in accordance with facility policy in three of seven records, specifically # 1, 4, and 6.
Client # 1, an active client, was admitted to the program on 10/26/11.
A case consultation was due to be completed no later than January 24, 2012.
The facility failed to document a case consultation as of 2/2/12.
Client # 4, an active client, was admitted to the program on 9/27/11.
A case consultation was due to be completed no later than December 26, 2011.
The facility failed to document a case consultation as of 2/2/12.
Client # 6, an active client, was admitted to the program on 10/25/11.
A case consultation was due to be completed no later than January 23, 2012.
The facility failed to document a case consultation as of 2/2/12.
The facility director confirmed the findings.
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Plan of Correction
The assigned supervisor met with the staff members assigned to client #1, client #4, and client #6 respectively; reviewed the standard requiring that client records include a documented case consultation every 90 days; and review proper documentation of Treatment Team discussion and recommendations. The assigned supervisors will monitor the client records of all staff members to ensure ongoing compliance. At the next quarterly Peer Utilization Review scheduled for May 2012, reviewers will be particularly attentive to properly documented case consultations.
By March 2, 2012 the Director of Clinical Services (DCS) will send an e-mail to all staff which reviews the requirement that all client records document a case consultation every 90 days. The DCS will review this client records documentation standard and proper documentation in detail at a staff meeting scheduled for May 1, 2012.
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