INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 3 - 5, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Stairways Behavioral Health Outpatient Drug and Alcohol 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 April 4, 2009. .
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Plan of Correction
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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the 2007 - 2008 annual report and an interview with the project director, the governing body failed to make available to the public the 2007 - 2008 annual report.
The findings include:
The 2007 - 2008 annual report was reviewed on March 3, 2009. The facility is publicly funded and required to make available to the public an annual report. The 2007 - 2008 fiscal year ended on June 30, 2008. The project director reports the 2007 - 2008 annual report was completed in October of 2008. The governing body failed to make the 2007 - 2008 annual report available to the public, as required.
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Plan of Correction
As discussed at the site visit, the annual report was completed in a timely manner. The public notice had not gone out as required but was placed in the legal notice section of the local newspaper on 3-3-09. In the future, the project director and corporate compliance officer will ensure that the public notice is posted and the report is available as required. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative polices and procedures and an interview with the Project Director, the facility failed to document the annual update of a written manual delineating project polices and procedures.
The findings include:
The administrative policies and procedures were reviewed on March 3, 2009. The project director failed to document the annual update of the written project policies and procedures, as required.
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Plan of Correction
Pior to this inspection, the CEO had always signed off on the annual policy review. After the change in project director, the current director had not signed off on the annual policy review. The CEO had reviewed this year's policies and signed off, the project director had also reviewed the policies but did not sign as this was not the established practice.
The current project director's signature line and date has now been added to the annual policy review page. The project director will ensure from now on that appropriate signatures appear on the annual policy review. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of the fire extinguisher upon staff employment, in one of one personnel records.
The findings include:
Four personnel records were reviewed. One personnel record required fire extinguisher training. The facility failed to document the completion of fire extinguisher training in personnel record # 2 within seven days of employment.
Employee # 2 was hired on February 1, 2009. Employee # 2 did not have documentation of the required fire extinguisher training as of March 5, 2009.
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Plan of Correction
Since the inspection date, the staff member has received the agency fire safety/extinguisher training. The training department coordinator will place appropriate documentation in the staff member's HR personnel file. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies, in one of one personnel records.
The findings include:
Four personnel records were reviewed. One personnel record required the completion of emergency training. The facility failed to document the completion of emergency training in personnel record # 2 within seven days of employment.
Employee # 2 was hired on February 1, 2009. Employee # 2 did not have documentation of the required emergency training as of March 5, 2009.
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Plan of Correction
Same issue as the previous citation. Since the inspection date, the staff member has received the agency emergency training. The training department coordinator will place appropriate documentation in the staff member's HR personnel file. |
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.
The findings include:
Four personnel records were reviewed on March 4, 2009. Three personnel records were counselors. Two personnel records required the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 3.
Employee # 3 was hired on July 11, 2007. The facility training year is from January through December. Employee # 3 only completed 20.5 clock hours of annual training in 2008.
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Plan of Correction
The employee was reminded of the necessary number of training hours (25)to complete per year. That employee is also currently registered for 6 additional hours of PCB approved training on 4-17-09. The project director will also monitor that all employees complete the required number of training hours per year. |