INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 10-11, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Esper Treatment Center Inc. 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 staff development records, the facility failed to document the completion of 25 hours of annual training required for counselors in two of three personnel records reviewed.The findings included:Six staff development records were reviewed on July 10, 2013. The facility training year is from July through June. The training year for July 2012 through June 2013 was reviewed. Three staff development records were counselors who were required to document the completion of 25 clock hours of annual training. The facility failed to document 25 hours of annual training in records # 4 & 5.Employee # 4 was hired on July 1, 2002, and completed 24.5 hours of annual training for the July 2012 through June 2013 training year.Employee # 5 was hired on August 22, 2006, and completed 16 hours of annual training for the July 2012 through June 2013 training year.An interview with project director confirmed the findings.
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Plan of Correction
The Clinical Director will review training hours quarterly and advise counselors as to how many hours they have and how many hours are needed to fulfill the 25 hour requirement. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services. The findings include:The facility's administrative records were reviewed for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services on July 10, 2013. The facility ' s fiscal year runs from January 1 to December 31. The facility did not document an independent financial audit for the 2012 fiscal year.An interview with project director confirmed the findings.This is a repeat citation. The facility was cited previously for noncompliance with this standard on July 29, 2011 and on August 11, 2010.
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Plan of Correction
The Project Director will put in another exception and be more concise in explaining the situation. The agency files taxes based on a calendar year so in the case that I am granted an extension from the IRS I will have no numbers to audit until October. I will put that in the exception. |