INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on February 6-7, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Discovery House 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 the 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
The facility failed to document that each counselor completed at least 25 hour of training annually.
The onsite inspection was conducted on February 6-7, 2017. The training year reviewed was January - December 2016. Staff #4 did not document the completion of at least 25 hours of training for the 2016 training year.
Staff #4 was hired as a counselor on 7/1/15. Staff #4 had 9 hours of training documented for the 2016 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors will obtain at least 25 hours of training annually. Training assessments will be done annually. Trainings will be scheduled from this annual assessment and documented in the training binder once completed, which the Clinical Supervisor will maintain. Clinical Supervisor will monitor progress on a monthly basis and assign trainings to counselors when necessary. This will be immediate and ongoing. Clinical Supervisor will be responsible for full compliance with this POC. |
705.24 (1) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(1) Provide bathrooms to accommodate staff, clients and other users of the facility.
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Observations
The facility failed to ventilate all bathrooms with an exhaust fan or window.
The physical plant inspection was conducted on February 7, 2017 at which time the exhaust fan in one of the rear bathrooms was found to be inoperable. There was no window in the bathroom.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The exhaust fan in the rear bathroom will be replaced by April 1, 2017. The Clinic Director will monitor for physical-plant compliance on a quarterly basis utilizing the Health and Safety check-list. Clinic Director will be responsible for full compliance. |
705.26 (1) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(1) Shall have a heating and cooling ventilation system that is adequate to maintain an indoor temperature of at least 65F in the winter. When indoor temperatures exceed 90F, mechanical ventilation such as fans or air conditioning shall be used.
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Observations
The facility failed to prohibit the use of heaters that are not permanently mounted or installed.
The physical plant inspection was conducted on February 7, 2017 at which time a portable heater was found on the floor of one of the counseling offices.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All heaters that are not permanently mounted or installed will be removed from all office spaces immediately. This issue will be addressed during team meetings on a quarterly basis in order to remain in compliance and ensure this deficiency does not recur. This will be immediate and ongoing. Clinic Director will be responsible for full compliance with this POC. |