INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 9, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Centre Counseling Associates 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 one of one applicable employee personnel records reviewed, the facility failed to provide documentation of at least 25 clock hours of annual training required for a counselor for the training year January-December 2022.
Employee # 1 was hired as the facility director/counselor on July 1, 2003 and was still in this position at the time of the inspection. After a review of employee #1's personnel record, there was 0 training hours recorded in the employee record.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The Program Director acknowledges that a mistake had been made in calculating the training hours in the years January 2022 to December 2022. There have been a total of 54 training hours recorded during the time period of January 2021 to February 2023. The Project Director also has a PA. Licenced Professional Counselor License which requires 30 training hours every 2 years. I miscalculated the hours for the 2 licenses because I usually coordinate the hours needed for the 2 programs to insure compliance with the facility license and the professional license requirements. The hours were split date wise so some of the hours were not counted in the correct time frame
and should have been recorded separately.
The Project Director shall within 60 days review the situation and put in place a more accurate monitoring system for these hours. The required hours shall be listed separately between the two programs to ensure the hours are recorded within the appropriate time periods. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of the fiscal management records, the facility failed to provide 2021 tax returns at the time of this inspection. The facility has been granted an exception that in lieu of obtaining the services of an accountant to conduct an annual financial audit, the facility would provide tax returns at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the February 23, 2022 inspection.
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Plan of Correction
Within 120 days the Project Director shall meet and try to formulate a solution with a financial advisor. The Project director shall then pursue this action to get everything in compliance as soon as possible The Project Director shall assure that this exception shall be in compliance for all future inspections |
709.34 (c) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.
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Observations
Based on a review of that facility's unusual incident records, the facility failed to report the department within 3 business days an unusual incident involving a significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.
There was documentation that the facility closed for services from December 12, 2022 until January 16, 2022 due to the facility's owner's health concerns. The Department was never notified of the closure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director was out of the office for about a month for health reasons. He did not realize that his personal illness would be classified as an unusual incident or he would have filed the paperwork. This discrepancy has been noted and a addition will be included in the Policy and Procedure to clarify that a personal illness that affects the facility shall be noted and appropriate paperwork shall ne submitted to BDAP. This will take effect immediately. |