INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 3, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clear Concepts Counseling (Lewistown) 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 documentation reviewed in the agency training files,one employee did not have the minimum number of training hours for the last training year. The findings include:Only nineteen hours of appropriately documented training was found in employee #6 training file on April 3, 2013 on-site inspection. The counselor required to have twenty-five training hours.This finding was confirmed by the Credentialing Coordinator on April 5, 2013 at the exiting interview.
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Plan of Correction
Our project will be in full compliance with this standard by 6/30/2013, which is the end of our current training year. By that date all employees will have received 25 training hours as is required by the standard. Due to a misunderstanding, this employee failed to follow through with the required training. This employee will seek out and attend trainings throughout the year which will address the areas set forth by the standard.The Director of Administration will monitor the employee training files throughout the training year to assure that each employee meets the required training hours. |
705.22 (1) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on an on-site physical plant inspection, the facility failed to maintain a safe and danger free environment.The findings include:A review of the building on April 3, 2013, revealed the carpet on the top step of the stair case leading to the inside second floor was torn and taped causing a safety hazard to the clients and staff.This was confirmed by the Credentialing Coordinator on April 3, 2013.
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Plan of Correction
Our facility is in full compliance with this standard as of 4/5/2013. During the physical plant inspection on 4/3/2013 the top step of the stair case leading to the inside second floor had a piece of bright yellow duct tape on it which alerts people that the step is a short (half) step and the tape is intended to get their attention. The bright yellow duct tape was torn but not intended to cover up torn or loose carpeting. The Project Director replaced the torn piece of tape with a new piece of bright yellow duct tape and in the future it will be replaced immediately upon being worn out. |