INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 9, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clear Concepts Counseling 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 May 2, 2009.
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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 the review of employee records, the facility failed to ensure that one out of one counselors obtained at least twenty-five hours of annual training.The findings include:Five employee records were reviewed on April 6, 2009. One counselor was required to have twenty-five training hours. The facility failed to provide documentation that employee # 12 obtained the mandatory number of annual training hours.
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Plan of Correction
Our facility will be in full compliance with this standard by 6/30/09, which is the end of our current training year. By that date each employee will have received 25 training hours as is required by the standard. Employee # 12 had failed to complete the required training due to personal issues. This employee will seek out and attend trainings throughout the year, which will address the areas set forth by the standard. Clinical Supervisor is responsible for ensuring the corrective action(s) is implemented. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document frequency of treatment on treatment plans in two of four client records.The findings include:Five client records were reviewed on April 9, 2009. Frequency of treatment was required to be identified in patient treatment plans in four of five records. The facility failed to document frequency of treatment in client records # 2 and 4.
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Plan of Correction
Our facility will be in full compliance with this standard by 4/30/2009. This standard and our agency policy relative to this standard will be reviewed with all counselors at our next staff meeting on 4/16/2009. The proper documentation of frequency of treatment in the client records will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance. |