INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 30, 2009 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on January 2, 2010.
|
Plan of Correction
|
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on a review of staff training and staff development records, the facility failed to provide a sufficient number of staff trained in first aid.
Findings:
The sole proprietor's staff development file was reviewed on November 30, 2009. The first aid training certification in the record expired on August 2008. The project director acknowledged the expiration of the first aid training
|
Plan of Correction
The facility director shall within 90 days be required to take a qualified First Aid course to update his training requirements under this section. |
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
Based on a review of the staff development record and an interview with the project director/counselor, the facility director/counselor failed to acquire twenty-five hours of training.
Findings:
The facility director/counselors's staff development record was reviewed on November 30, 2009. The counselor failed to acquire any hours of training for the training year January 2008 through December 2008, which is the prior training year.
|
Plan of Correction
The facility director shall enroll and complete sufficient training modules to correct the deficiencies for last year and fulfill the requirements for this year. Time frame 6 months. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
Based on a tour of the physical plant and an interview with the director, the facility failed to annually inspect facility fire extinguishers.
Findings:
A tour of the physical plant on November 30, 2009 documented three of three fire extinguishers have not been inspected annually. The last inspection was completed on August 2008 as evidenced with inspection tags..
|
Plan of Correction
The facility director shall request in writing that Nittany Realty, the owners of the building, have the required fire extinguisher inspection performed as soon as possible. Time frame 30 days. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
|
Observations
Based on a interview with the project director the facility failed to make provisions through written agreement with a licensed hospital or physician for 24 hour emergency psychiatric and medical coverage.
Findings:
On November 30, 2009 an interview with the project director confirmed that the facility failed to document a written agreement with a licensed hospital, or physician, for 24-hour emergency psychiatric and medical coverage.
|
Plan of Correction
The facility director shall contact the Mount Nittany Medical Center in State College and renew the coverage that was established several years ago but was not redocumented to date. Time Frame 60 days. |
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.
|
Observations
Based on an interview with the facility director the facility failed to obtain the services of an accountant for an annual audit since program inception.
Findings:
Based on an interview with the facility director on November 30, 2009 it was determined the facility has not completed an audit of financial activities associated with the drug and alcohol abuse services since the program inception date of February 3, 2006.
|
Plan of Correction
The facility director shal draft a letter to the appropriate PA> Dept of Health official to request a waiver from having a formal accounting done because if the nature of ownership of the facility, the lack of the receipt any public funding,and the fact that the facility director is the only employee of the facility. Time frame 90 days. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of three client records, the project failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Findings:
Three of three client records reviewed on November 30, 2009 between the hours of 11:00 and 13:00 failed to assure counseling services were provided as defined in the individual treatment plan.
Client record # 1 - Admitted March 20, 2008. The treatment plan established on March 20, 2008 included documentation of individual counseling service frequency as one time a week. Based on a review of progress notes for the period of May 2008 through November 2009 counseling frequency was documented only one time a month without frequency changes noted in either progress notes or sixty day treatment plan updates.
Client record # 2 - Admitted December 4, 2007. The treatment plan established on December 7, 2007 included documentation of individual counseling service frequency as one time a week. Based on a review of progress notes for the period of December 2007 through November 2009 counseling frequency was documented only one time a month without frequency changes noted in either progress notes or sixty day treatment plan updates.
Client record #3 - Admitted December 12, 2007. The treatment plan established on December 12, 2007 included documentation of individual counseling service frequency as one time a week. Based on a review of progress notes for the period of December 2007 through November 2009 counseling frequency was documented only one time a month without frequency changes noted in either progress notes or sixty day treatment plan updates.
|
Plan of Correction
The facility director shall examine all current client records and all closed ones since the last BDAP inspection and make any corrections that are necessary to accurately document the frequency of treatment in the client record. This is noted and will assure that all client records in the future are updated in a timely and accurate nmanner |
709.93(a)(3) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(3) Record of services provided.
|
Observations
Based on a review of client records and an interview with the project director the facility failed to document a record of services provided in three of three records.
Finding:
Three active records reviewed on November 30, 2009 failed to document a record of services provided. Client records # 1, 2 and 3 failed to include documentation of a record of services.
|
Plan of Correction
The facility director shall examine all current client records and all closed records since the last BDAP inspection and place in each record a summary of client services documenting the type and frequency of services rendered. Time frame 60 days. |