INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 19, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, McDermott Counseling, LLC 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 one personnel record, the sole proprietor failed to complete 25 clock hours of training annually.
Employee #1 was hired as the Project Director/ Facility Director/ Counselor on August 1, 2010 and is current in that position. Employee #1 is the sole proprietor and responsible for completing 25 clock hours of training annually. During 2021, only 21.25 clock hours were documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director being sole owner and therapist is responsible for 25 continuing education credits per year. There are 4 missing hours that were not documented this past year. Project director will ensure with 2023 and ongoing years-better accounting of exact credit hours being restored. There is the Penn State conference attended by project director every year -earning 12 credits. Director will schedule at least one to two additional conferences totaling 13 credits to equal 25 credits. Project Director is now registered for Penn State March 2023 conference.13 additional hours will be attended with additional conferences through 2023-project director will participate with this requirement. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from January 2022 to December 2022, the facility failed to document that alternate exits were used during fire drills. The fire drill logs only specified the first floor rather than a specific exit used.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
McDermott Counseling conducts fire drills as required by Department of Drug and Alcohol programs. There are 2 entrance/exits on the first floor-one door is located in office area. There is another door- primary door where patients enter the waiting room from outside. Fire drills are conducted utilizing both doors. Project Director will include which door was utilized as entrance/exit with each fire drill. This designation will be included in 2023 and ongoing fire drills. Project Director will be responsible for including which door is being used in each fire drill. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents submitted, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
The facility submitted their own statement of profit and loss rather than obtaining the services of a certified public accountant.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project director will submit fiscal exemption to department of drug and alcohol by January 31,2023 If exemption is not approved-project director will retain an independent certified accounting firm to complete an audit of activities associated with drug and alcohol, programming. |