INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on April 24, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Lehigh County Center for Recovery 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 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #3, #7 and #8 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired as a clinical supervisor on January 7, 2019 and was due to have the communicable disease trainings no later than January 7, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
Employee #7 was hired as a counselor on July 30, 2018 and was due to have the communicable disease trainings no later than July 30, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
Employee #8 was hired as a direct support professional on April 3, 2018 and was due to have the communicable disease trainings no later than April 3, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
On February 6th 2020, Program Director developed a monitoring system to track employee's mandatory communicable disease training. Program Director will monitor tracking of training on a monthly basis and schedule needed training. |
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 personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employee #7's employee record.
Employee #7 was hired as a counselor on July 30, 2018 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2019 through December 30, 2019. Employee #7's employee record only documented 23.5 hours of annual training for the training year reviewed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
On February 6, 2020 Program Director has developed a monitoring system to track counselors training hours. Program Director and Clinical Director will monitor, on a monthly basis, staff's training and have staff schedule training as needed. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drills from February 2019 until March 2020, the facility failed to ensure that a fire drill was conduct during sleeping hours at least every 6 months. Based on the fire drill log an overnight drill was due to be completed in July 2019, however, was not completed until September 2019 and another overnight drill to be completed in March 2020, however, was not completed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
On April 29, 2020 Program Director and Safety Officer developed a yearly schedule for fire drills that includes what shift the drill will be conducted. Program Director and Safety officer will monitor that overnight drills will be conducted at least every 6 months and documented in the fire safety manual. |