INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 27, 2006 through July 28, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on August 21, 2006.
|
Plan of Correction
|
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.
|
Observations
Employee #1 completed 6.5 of the required 25 hours during the training year reviewed.
|
Plan of Correction
PM will monitor, identify and facilitate training opportunities for employee during the coming year such that employee receives at least minimum of 25 hours required. Completion date is 8/1/06 and ongoing to 7/1/07 |
705.21 (2) LICENSURE General req. for nonresidential facilities.
705.21. General requirements for nonresidential facilities.
The nonresidential facility shall:
(2) Have a certificate of occupancy from the Department of Labor and Industry or its local equivalent.
|
Observations
A certificate of occupancy was not presented at the time of the inspection.
|
Plan of Correction
C of O to be faxed on 8/15/06 by Program Manager. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
Counseling sessions can be heard outside the counseling room.
|
Plan of Correction
Drexel University, in conjunction with building manager to rectify noise issue by making all changes necessary to bring into compliance. Until all construction is completed, program will be using multiple "white noise" machines throughout office space.
1. Date for implementation of noise machines is 8/18/06.
2. Estimated date for completion of demising wall between Caring Together and adjoining office suite is mid-September 06.
3. Completion of all sound-proofing is estimated at 12/1/06
|
705.23 (4) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(4) Locate counseling areas so that noise does not disturb or interfere with counseling sessions.
|
Observations
Counseling sessions are disturbed by the noise coming from other areas of the building.
|
Plan of Correction
Drexel University, in conjunction with building manager to rectify noise issue by making all changes necessary to bring into compliance. Until all construction is completed, program will be using multiple "white noise" machines throughout office space.
1. Date for implementation of noise machines is 8/18/06.
2. Estimated date for completion of demising wall between Caring Together and adjoining office suite is mid-September 06.
3. Completion of all sound-proofing is estimated at 12/1/06
|
705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
|
Observations
There were no smoke detectors observed throughout the facility.
|
Plan of Correction
Install smoke detectors in hallways and several community areas. |
711.92(b) LICENSURE Letters of Agreement
711.92. Treatment and rehabilitation services.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
|
Observations
Most letters of agreement or understanding were expired. The agreements did not always state what services would be provided to the project clients being considered for referral.
|
Plan of Correction
The letters of agreement will be revised to include the required information and all expired agreements will be renewed. |