INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 18-19, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to provide documentation of individual training plans in five of twelve personnel records. The findings include:Thirteen personnel records and the facility staffing requirements summary report were reviewed on December 18-19, 2012. Individual training plans were required in twelve personnel records. The facility' s training year is July 1- June 30. Per agency policy, individual training plans are to be completed by June 30 of each training year. The facility did not document individual training plans for the July 1, 2012 - June 30, 2013 training year in personnel records # 1, 9, 11, 12 and 13. The clinical supervisor and compliance officer were interviewed on December 19, 2012 and confirmed the findings.
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Plan of Correction
Training plans for all identified staff have been completed for the 2012-13 training year.
Compliance officer and Clinical Supervisor will be responsible for on going compliance oversight.
Completed 1/18/2013 |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum in four of four personnel records. The findings include:Thirteen personnel records were reviewed on December 18-19, 2012. Four personal records were reviewed for compliance with the 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Per regulation, counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment. There was no documentation of the required training in personnel records # 8, 11, 12 and 13. Employee # 8 was hired as a counselor on November 2, 2009. At least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum was to be completed by November 2, 2010. There was no documentation the training had been completed. Employee # 11 was hired as a case manager on August 1, 2006. Six hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum was to be completed by August 1, 2008. There was no documentation the training had been completed. Employee # 12 was hired as medical records/ front desk receptionist on July 1, 2007. Six hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum was to be completed by July 1, 2009. There was no documentation the training had been completed. Employee # 13 was hired as a fiscal technician March 12, 2003. Six hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum was to be completed by July 1, 2009. There was no documentation the training had been completed. The clinical supervisor and compliance officer were interviewed on December 19, 2012 and confirmed the findings.
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Plan of Correction
Personnel who have not had the mandatory Communicable Disease training will be scheduled for the next available,accessible training. It appears that there is an STD/TB one scheduled in May in Clarion.We will continue to monitor the training site for AIDS/HIV.
The Compliance Officer and the Clinical Supervisor will be responsible for assuring the trainings are provided. In the future,all new hires for the support staff departments will be scheduled for the next available training as part of their orientation.
The one therapist not having these trainings was an oversight and will be corrected. Additionally, a new training system has been purchased for the Agency which will allow easy monitoring of completed trainings.
Target date for completion is June 30,2013. |
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 document the completion of 25 clock hours of annual training required for counselors in four of six personnel records.The findings include:Thirteen personnel records were reviewed on December 18-19, 2012. Seven personnel records pertained to counselors. Six personnel records required the completion of 25 clock hours of annual training. The 2011/2012 training year was reviewed. The facility failed to document 25 clock hours of annual training in personnel records # 4, 5, 6 and 7.Employee # 4 was hired on June 23, 2008. There was only 12 clock hours of annual training documented for the 2011/2012 training year. Employee # 5 was hired on July 9, 2007. There was only 1 clock hour of annual training documented for the 2011/2012 training year. Employee # 6 was hired on June 23, 2009. There was only 10 clock hours of annual training documented for the 2011/2012 training year. Employee # 7 was hired on June 30, 2008. There was only 14 clock hours of annual training documented for the 2011/2012 training year. The clinical supervisor and compliance officer were interviewed on December 19, 2012 and confirmed the findings.
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Plan of Correction
A review of the current training year record indicates that this is already being addressed at a reasonable pace. As the issue for the therapists was the confusion of calendar year vs. fiscal year, the therapists now understand the time parameters.
It will be the responsibility of the Clinical Supervisor and the therapist to monitor compliance with the hours needed.
The completion of this plan will be July 1, 2013. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the annual report, the facility failed to make an annual report available to the public which included a financial statement of income and expenses.The findings include:The annual report for the 2011/2012 fiscal year was reviewed on December 18, 2012. The annual report did not include a financial statement of income and expenses. The Project Director was interviewed on December 18, 2012 and confirmed the findings.
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Plan of Correction
Upon completion of the Audit, a copy of the budget for the D/A Program will be attached to the Annual report. This is already presented to the board during the review of the Annual audit. The attachment would be for the public.
The Facility Director will be responsible to monitor compliance with this regulation.
Target Date for completion is January 31,2013. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records, the client handbook and the physical plant inspection, the facility failed to provide documentation that clients were informed of their rights in six of six client records. The findings include:Twelve client records and the client handbook were reviewed on December 18-19, 2012. The physical plant inspection was conducted on December 19, 2012. Six client records required documentation that the client was informed of their rights. There was no documentation that the clients were informed that they had (3) the right to inspect his own records. That the project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file. (4) The client has the right to appeal a decision limiting access to his records to the project director. (5) The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records and (6) The client has the right to submit rebuttal data or memoranda to his own records in client records # 1, 2, 3, 4, 5 and 6. The clinical supervisor and compliance officer were interviewed on December 19 and did not dispute the findings.
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Plan of Correction
In response to this regulation, the Clients' rights, as stated in the regulations, and stated in our Policy and Procedure manual , will be included in the client orientation packet at the time of admission. A copy of the entire policy will be given and reviewed at intake.
Compliance Officer is responsible for posting the rights.
Target date for completion is January 31,2013. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultations in four of five client records. The findings include:Twelve client records were reviewed on December 18-19, 2012. Five client records required case consultations. Per agency policy, case consults are to be completed at the time of the treatment and rehabilitation plan updates. There was no documentation of case consultations in client records # 2, 3, 4 and 5. Client # 2 was admitted on August 22, 2012. A case consultation note, dated December 17, 2012 was documented in the client's records but did not document that staff members had participated in the consultation. Only the counselor's signature was documented. Client # 3 was admitted on July 18, 2012. A case consultation note, dated December 2, 2012 was documented in the client's records but did not document that staff members had participated in the consultation. Only the counselor's signature was documented. Client # 4 was admitted on June 27, 2012. A case consultation was due to be completed by October 1, 2012. There was no documentation of a case consultation in the client's record. Client # 5 was admitted on August 30, 2012. A case consultation note, dated November 28, 2012 was documented in the client's records but did not document that staff members had participated in the consultation. Only the counselor's signature was documented. The clinical supervisor and compliance officer were interviewed on December 19, 2012 and did not dispute the findings.
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Plan of Correction
While case consultations were completed in most files, the procedure for signing the form within the EMR had not been developed. Currently, additional signature boxes have been added and a notification protocol developed.
The Compliance Officer and the Clinicla Supervisor are responsible for oversite of this regulation.
Currently completed. |