INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 20, 2008 and October 21, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Chester County Intermediate Unit - Changes 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 November 25, 2008.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of four personnel records on October 21, 2008, the facility failed to ensure the person appointed to the position of project director met with qualifications of the position.
Findings:
A review of the personnel record for Employee #1 indicated that the documentation for educational requirements for the position of project/facility director position did not meet standard regulations. The documentation indicated Employee #1 has a Doctoral degree in Education Administration. A conversation with Employee #2 on October 21, 2008 confirmed the documentation presented.
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Plan of Correction
An exception for Project Directors educational qualifications will be requested of the Department by the CCIU Board of Director's representative. The exception will be specific for the CCIU Changes program. The exception will be submitted by the facilities director by December 22, 2008 |
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 four personnel records on October 21, 2008, the facility failed to provide documentation of at least 12 clock hours of training annually for the project director (#1).
Findings:
There was no training documented for the facility's training year for the project director (#1).
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Plan of Correction
Project Director will attend and provide all necessary documentation of 12 hours annually of training. Documentation will miinimally include certificates of completion as well as an evaluation of the training. All documentation will be forwarded to the Facitites Director for filing in the on-site personnel file at Changes and be available for inspection at all times. |