INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on September 18-19, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Lebanon Treatment Center 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 the inspection:
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide a written individual training plan for each employee in two of nine personnel records reviewed. The facility training year reviewed was March 2017 to February 2018.
Employee # 1 was hired on 11/29/2011 and was still in the position. There was no individual training plan documented for the training year reviewed.
Employee # 9 was hired on 4/1/2015 and was still in the position. There was no individual training plan documented for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A training plan has been created for Employee 1 and Employee 9 as of 10/11/017. Training plans will be developed upon hire and annually thereafter. Program Director and Regional Director will complete quarterly employee file audits to ensure compliance with training plans for all staff. |
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 personnel records, the facility failed to provide documentation of HIV/AIDS and TB/STD and other health related topics training in two of nine applicable records reviewed.
Employee #8 was hired on 1/4/2016 as a counselor assistant and was still in the position. The employee was required to obtain six hours of HIV/AIDS and 4 hours of TB/STD training by 1/4/2017. However, there was no documentation of either training in the personnel file.
Employee #9 was hired on 4/1/2015 as a Billing Specialist and was still in the position. The employee was required to obtain 4 hours of TB/STD training by 4/1/2017. However, there was no documentation of either training in the personnel file.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
0067#
The Clinical Supervisor will develop a tracking tool for each counselor and Director for all support staff to monitor all Trainings required and Trainings Completed. The tool was completed and submitted to the Facility Director on 10/10/2017. Individual reminders and an available training list will be forwarded monthly to each staff member until annual requirements are met. Employee # 5 and Employee # 9 have since enrolled in trainings to meet the requirement. Employee # 8 has resigned his position on September 30, 2017. Employees #5 has scheduled training for December 3,2017and employee #9 has scheduled October 23,2017,November 2,2017, and December 4,2017 training to meet the requirement. This corrective action will be completed on December 5,2017.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project directors and facility directors in one of two personnel records reviewed.
Employee #1 was hired on 11/29/2011 as the project director and was still in the position. The facility training year reviewed was March 2016 to February 2017. Employee #1 did not have documentation of any training hours for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director who was Promoted to Project Director in January of 2017 will complete his training hours by the end of December 2017. Program Director and Regional Director will track hours via a spreadsheet of all employees training hours on a quarterly basis to ensure compliance. |
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 personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of two personnel records reviewed.
Employee # 5 was hired on 11/2/2015 as a counselor and was still in the position. The facility training year reviewed was March 2016 through February 2017. Employee # 5 only had documentation for 9 completed hours of annual training in the personnel record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
0083#
Clinical Supervisor has developed a tracking tool for each counselor to monitor both training required and trainings completed. Tracking tool was submitted to Program Director on October 10, 2017. Individual reminders and a list of available trainings will be forwarded to each counselor monthly beginning October, 2017 until requirements are met. This will also be monitored Clinic Director via monthly All Staff Meetings. Employee # 8 has resigned his position on September 30, 2017. Employees #5 has scheduled training for December 3,2017and employee #9 has scheduled October 23,2017,November 2,2017, and December 4,2017 training to meet the requirement. This corrective action will be completed on December 5,2017.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document an annual written individual staff performance evaluation in 1 of 9 personnel records reviewed.
Employee #1 was hired on 11/29/2011 as the Project Director and was still in the position. There was no documented annual performance evalution presented to Employee #1 since the previous licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director who was Promoted to Project Director in January of 2017 will have an Annual Performance Evaluation completed upon the end of his first year at Project Director (January 2018). The annual Performance Evaluation will be provided to the Regional Directors for submission for licensing visits. The Regional Director and Program Director will complete a year end evaluation Audit to ensure compliance. The Human Resource Business Partner for the region will monitor yearly evaluations for each facility and make sure each individual director has the updated copy of the Performance evaluation on file at the programs. The Performance Evaluation that was missing has been sent to the program for compliance. The Regional Director will ensure that this does not happen in the future. |