INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 5, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Council of Southeast Pennsylvania, Inc. 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that the project director completed at least 12 clock hours of training during the facility's January 1, 2019 through June 30, 2020 training year in one of one applicable personnel record reviewed.
Employee #1 was hired as the Project Director on November 1, 2018. The personnel record documented 6 hours of training received during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 4/12/2021,the following process is in place to ensure that the Project Director is supported in completing the requirement of 12 hours of training annually. The Facility Director will monitor training hours quarterly to ensure that training hours are completed and documented. This will be accomplished by a quarterly reminder and provision of any training resources available.
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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 a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's previous two training years in one of one applicable personnel record reviewed.
Employee #2 was hired as a counselor on April 11, 2011. The personnel record documented 20.75 hours of training received during the July 1, 2018 through June 30, 2019 training year and 23 hours of training received during the July 1, 2019 through June 30, 2020 training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 4/12/2021,the following process is in place to ensure that all Counselors are monitored in completing the requirement of 12 hours of training annually. The Facility Director will monitor training hours quarterly to ensure that training hours are completed and documented. This will be accomplished by a quarterly reminder and provision of any training resources available.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's April 2019 through March 2021 fire drill log, the facility failed to document on their written fire drill log the amount of time it took for evacuation for the drills conducted in the months of October 2020 and January 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The documentation requirements for Fire Drills have been reviewed with all levels of treatment staff to ensure all sections of logs are completed. The Facility Director will review the Fire Drill Logs to confirm that all information is documented after each Fire Drill. |