INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 19-20, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health-HA, INC 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 the review of personnel records, the facility failed to document that counselors completed 25 clock hours of training annually in one of three personnel records.
The findings include:
Eight personnel records were reviewed on September 19-20, 2013. Three personnel records pertained to counselors and required 25 clock hours of training annually. The January- December, 2012 training year was reviewed. The facility did not document 25 clock hours of annual training in personnel record # 5.
Employee # 5 was hired as a counselor on June 21, 2010. There were 19 hours of training documented for the 2012 training year.
The findings were reviewed with the Facility Director and the Clinical Supervisor on September 20, 2013 and were not disputed.
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Plan of Correction
Program Director met with the Clinical Supervisor and Senior Counselor to review training requirements for counselors and the 01/09 Licensing Alert. Program Director held an all staff meeting to review the requirements with each Associate. Program Director informed all Associates that each counselor are to complete at least 25 clock hours of training annually in areas and refer to the licensing alert per Division of Drug and Alcohol Program Licensure if they are unsure whether the trainings they have attended or are planning to attend is an approved DDAPL training. The Clinical Supervisor will be responsible for ensuring that all Associates meet the training requirements. The Program Director will be responsible for overseeing the completion of this process. The Program Director will also keep a binder with DDAPL Licensing Alerts for staff to review. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on the physical plant inspection, the facility failed to provide exhaust fans or windows in three bathrooms.
The findings include:
The physical plant inspection was conducted on September 20, 2013. The two client bathrooms and the one guest bathroom were observed to have inoperable exhaust fans and no windows.
The Clinical Supervisor was present during the inspection and confirmed the findings.
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Plan of Correction
Program Director contacted Home Office in regards to the citation and inquired about installation of exhaust fans in the clinic bathrooms. Home Office confirmed that exhaust fans were put into bathrooms per building codes and regulations. Program Director contacted TUDI Mechanical Systems to schedule maintenance on the exhaust fans. TUDI reported that 4 of the 6 exhaust fan motors needed replaced and the tripping breaker kept the other fans from working. They also reported that the timer was set backwards causing the exhaust fans to run in the evening instead of during clinic hours. He stated this is why there is dust in the vents. He disconnected the bad motors from the circuit an adjusted the fan timer. Two of the six motors he reported were running properly. They will email a quote to replace the motors. Program Director will approve the quote once the quote is received. TUDI will complete all repairs once the parts are delivered. The Program Director will be responsible for overseeing the completion of this process. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of nine client records.
The findings include:
Eleven client records were reviewed on September 19-20, 2013. Nine of the client records required an individual treatment and rehabilitation plan which included the type and frequency of treatment and rehabilitation services. The individual treatment and rehabilitation plans contained in client records # 2, 3, 5 and 9 did not include the type and frequency of treatment and rehabilitation services
Client # 2 was admitted on July 19, 2013. The individual treatment and rehabilitation plan was developed on August 8, 2013, but did not include the type and frequency of treatment services.
Client #3 was admitted on June 5, 2013. The individual treatment and rehabilitation plan was developed on July 2, 2013, but did not include the type and frequency of treatment services.
Client #5 was admitted on April 8, 2013. The individual treatment and rehabilitation plan was developed on May 28, 2013, but did not include the type and frequency of treatment services.
Client # 9 was admitted to outpatient treatment on January 16, 2013. The individual treatment and rehabilitation plan was developed on February 21, 2013, but did not include the type and frequency of treatment services
The findings were reviewed with the Facility Director and the Clinical Supervisor on September 20, 2013 and were not disputed.
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Plan of Correction
Program Director met with the Clinical Supervisor and Senior Counselor to review the citation and Plan of Correction. On October 03, 2013 during an ALL staff meeting, the Clinical Supervisor reviewed with the Associates the citation and instructed them to include the counseling objective for all patients under dimension 4. The Clinical Supervisor prior to approving all Treatment Plans will make sure that the required information is included in the Treatment Plan under the correction dimension. If the information is not listed the Clinical Supervisor will notify the appropriate counselor and cc the Senior Counselor informing them the Treatment Plan will not be approved due to not meeting the state requirements. The Associate will be asked to make the corrections, review it with the patient and resubmit for approval. The Program Director will be responsible for overseeing the completion of this process. |