INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 24, 2024 through September 26, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, St. Luke's Penn Foundation 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 personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of annual training during the facility's July 1, 2023 through June 30, 2024 training year in one of five applicable personnel records reviewed.
Employee #11 was hired as a counselor on November 22, 2021. The personnel record documented 20 hours and 15 minutes of training during the training year reviewed.
This is a repeat citation from the October 26, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 11/1/2024, clinical supervisors will review annual training requirements with counseling staff in group supervision. Clinical supervisors will review training records quarterly to ensure counselors are working toward meeting training hours. The clinical supervisor will assign trainings in the My E-learning systems as needed to ensure training requirements are met. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include documentation of follow-up information, in one of three applicable client records reviewed.
Client # 20 was admitted into the outpatient activity on March 26, 2024 and was discharged on August 19, 2024. There was no follow up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 11/1/2024 the medical receptionist team will be re-trained in completing follow up call post discharge from the outpatient program The calls will be conducted within 7 days of discharge and documented in the client chart. Clinical supervisors will conduct monthly chart audits to ensure compliance with this regulation. |