INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 21, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clear Concepts Counseling 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 (SRFSR) and six personnel records, the facility failed to document in one personnel record the completion of 25 clock hours of annual training required for counselors.Employee #3 was hired as a counselor on July 1, 1996 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July 1, 2019 through June 30, 2020. Employee #3's personnel record only documented 10 hours of annual training for the training year reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #3 will have received 25 training hours as is required by the standard. Employee #3 had failed to complete the required trainings for training year July 1, 2019 through June 30, 2020. This employee will seek out & attend trainings throughout the year, which will address the areas set forth by the standard. Our facility will be in full compliance with this standard by 06/30/2021, which is the end of our current training year.
Clinical Supervisor is responsible for ensuring the corrective action(s) is implemented. In the future, the Project Director will conduct quarterly reviews of all training hours to ensure that this standard is being complied with.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of nine fire drills submitted, the facility failed to set off a fire alarm or smoke detector during each fire drill in six of the fire drills reviewed.The smoke detector was not set off during the fire drills on September 18, 2020, October 6, 2020, December 10, 2020, January 26, 2021, March 18, 2021 and April 5, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project will be in full compliance with this standard beginning immediately. Starting May 2021, the staff at this facility will conduct fire drills with the smoke detector being set off during the monthly fire drills and will be recorded on the fire drill log.
This standard has been reviewed and communicated to all staff on 4/22/21 and will also be reviewed during staff meeting on May 20, 2021 and will be reviewed every month by the Project Director to ensure the correct completion of the fire drill and fire drill records are conducted and documented to meet this standard.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of seven client records, the facility failed to develop written policies and procedures on client rights identifying the project may not discriminate on the basis of creed, sex, or religion in seven out of seven records.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. Counselors will review and update all current client's on the updated "client rights" during the next scheduled session and will have all client charts up to date by May 30, 2021. This standard has been reviewed and communicated to all staff on 4/22/2021 and will be reviewed again during our agency staff meeting on May 20, 2021.
Our facility will obtain the correct consent from client regarding the client rights. Proper completion of the required consent forms, including name of person/agency or organization, date, event, specific information disclosed and condition as well as the dated signature of a witness and the expiration date of the consent and a copy will be kept in the client record.
The Project Director updated the "Client Rights" (on 4/22/21 and all staff were informed up the updated "client rights") in order to include the information that the client rights identify our project may not discriminate on the basis of creed, sex, or religion. Our facility will begin implementing the updated client rights immediately.
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