INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on December 19-20, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Parkside Recovery 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of personnel/training records on December 19-20, 2017, the facility failed to ensure that the clinical supervisor had the required clinical supervision training in one of one clinical supervisor record reviewed.
Employee #2 was promoted to Clinical Supervisor on May 2, 2016. The employee did not have two years of prior supervisory experience in the provision of clinical services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor has already identified the next Clinical Supervisor Training, and will be schedule to attend the next available one. He will attend within the next 6 months. |
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/training records on December 19-20, 2017,, the facility failed to provide documentation of TB/STD training in one of eleven applicable records reviewed
Employee #11 was hired as a Counselor on November 19, 2015. The employee was required to obtain four hours of TB/STD training by November 19, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee#11 is scheduled to attend TB/STD Training on 2/23/2018. All other staff who have not had this training will also attend on this date. |
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/training records reviewed on December 19-20, 2017, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of three records reviewed.
Employee #3 was hired as a counselor on July 18, 2005. The facility training year reviewed was from July 1, 2016 through June 30, 2017. Employee #3 only completed 22 clock hours of annual training for the reviewed training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff who do not attend their required training will receive verbal consultation and possible corrective action plans if they are not completing their mandated training hours. Staff training requirement will be reviewed monthly by the director and clinical supervisor, and will be added to their regular clinical supervision session to ensure compliance. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel/training records on December 19-20, 2017, the facility failed to instruct staff in the use of the fire extinguisher upon employment in three of eleven records reviewed.
Employee #6 was hired as a Counselor on June 12, 2017.
Employee #8 was hired as a Counselor on October 2, 2017.
Employee #10 was hired as a Counselor on November 6, 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff are required to complete fire extinguisher training on the first day of employment at the mandatory Day 1 Training. In addition, all staff will complete manual training and sign an attestation that it is complete within the first 7 days of employment moving forward at the 5429 Germantown Avenue site. This will be kept in the staff folder held on site.
The Administrative Assistant will meet with all staff within the first 5 days, and this will be approved by the Program Director. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel/training records on December 19-20, 2017, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in three of eleven records reviewed.
Employee #6 was hired as a Counselor on June 12, 2017.
Employee #8 was hired as a Counselor on October 2, 2017.
Employee #10 was hired as a Counselor on November 6, 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff are required to complete emergency training on the first day of employment at the mandatory Day 1 Training. In addition, all staff will complete manual training and sign an attestation that it is complete within the first 7 days of employment moving forward at the 5429 Germantown Avenue site. This will be kept in the staff folder held on site.
The Administrative Assistant will meet with all staff within the first 5 days, and this will be approved by the Program Director. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records on December 19-20, 2017, the facility failed to obtain an informed and voluntary consent in four of eight records reviewed.
Client #4 was admitted to treatment on July 6, 2015 and is still an active client. The facility failed to obtain an updated informed and voluntary consent from the client for the funding source. The release in the client record expired on June 16, 2017.
Client # 6 was admitted to treatment on June 1, 2017 and is still an active client. The release for Treatment Court in the client record was authorized on May 31, 2017 but did not have a documented expiration date.
Client #7 was admitted to treatment on February 10, 2016 and was discharged on September 22, 2017. The facility failed to obtain an updated informed and voluntary consent from the client for the funding source.
Client #8 transferred from the methadone program to buprenorphine treatment on March 15, 2017 and is still an active client. The facility failed to obtain an updated informed and voluntary consent from the client for his funding source. Also, the release for the laboratory screening urines collected expired on May 7, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All charts will be reviewed by their counselor annually, and during this written annual review, counselors will be required to review all releases. Any release that needs updated will be completed at the annual review.
Counselors who do not complete these release updates during this session will receive verbal counseling or corrective action plans.
Counselors will be responsible for reviewing releases in all of their active cases when treatment plans are completed. |