INITIAL COMMENTS
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This report is a result of a licensure renewal inspection. The physical plant inspection was conducted on December 29, 2022, and the client records review inspection was conducted on February 13, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling and Psychiatric Services 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(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 ten personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that one employee received the minimum of six hours of HIV/AIDS training and three employees received at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #4 was hired as a counselor on August 12, 2021 and was due to have the communicable disease trainings no later than August 12, 2022. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #8 was hired as a counselor on April 9, 2020 and was due to have the communicable disease trainings no later than April 9, 2021. Employee #8 received HIV/AIDS training on October 6, 2021 and TB/STD training on February 23, 2022.
Employee #9 was hired as a counselor on March 11, 2021 and was due to have the communicable disease trainings no later than March 11, 2022. Employee # 9 completed TB/STD training on April 21, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 is registered to attend the communicable disease training on 5/26/23. During orientation at PA Counseling Services, all counselors are provided a training plan which outlines required trainings and the required timeframes for completion of these trainings. The Director of Implementation for Outpatient Services will remind all newly hired clinical staff that the HIV/AIDS and TB/STD trainings must be completed within the first year of employment. The facility's Office Manager/Administrator will be responsible to monitor completion of the required trainings and to follow-up with staff as needed to ensure completion within the regulatory guidelines. |
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 the Staffing Requirements Facility Summary Report and ten personnel records, the facility failed to document the completion of 25 clock hours of annual training required for one counselor reviewed.
Employee #7 was hired as a counselor on June 6, 2019 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2022 through December 31, 2022. Employee # 6's record only documented 18.5 hours of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Pennsylvania Counseling Services was operating under the assumption that training hours could be prorated for staff who did not work a full calendar year due to a leave of absence/family medical leave act. Employee #7 was on FMLA from 8/22/22-11/14/22. This was an administrative error. Going forward, the Human Resources Department will remind any clinical staff that they are still expected to complete the required hours of annual training despite taking a leave of absence or FMLA. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of six records reviewed.
Client #1 was admitted on October 20, 2022 and was still active at the time of the inspection. A treatment plan was completed on November 16, 2022, and the next update was due no later than January 16, 2023; however, the next update was completed on February 2, 2023.
Client #2 was admitted on September 21, 2022 and was still active at the time of the inspection. A treatment plan update was completed on December 6, 2022, and the next update was due no later than February 6, 2023; however, it was not completed until February 7, 2023.
Client #5 was admitted on September 6, 2022 and discharged on December 9, 2022. A treatment plan was completed on September 26, 2022, and the next update was due no later than November 26, 2022; however, there is no documentation that one was completed.
Client #6 was admitted on February 14, 2022 and discharged on June 9, 2022. A treatment plan was completed on March 11, 2022, and the next update was due no later than May 11, 2022; however, it was completed on May 13, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Implementation for Outpatient Services provided re-education to all clinical staff regarding treatment plan timeframes during a staff meeting held on 3/27/23. The facility's Office Administrator will be responsible for ongoing compliance and will track the completion of treatment plan updates for all clients. The Office Administrator will oversee that clinical staff are re-educated as needed to review and update treatment plans at least every 60 days. |