INITIAL COMMENTS
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This report is a result of an onsite licensure renewal inspection. The inspection was conducted on April 5, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Clear Concepts Counseling (Mifflintown) was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 agency training files during the onsite inspection held it was determined that one employee did not have the minimum number of training hours for the last training year. The findings include:Nineteen hours of appropriately documented training was found in employee #4 training file on April 3, 2013 on-site inspection. The counselor is 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. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a client record review, the facility failed to complete psychosocial evaluations as stated in agency policy in two of five client records.The findings include:Six complete outpatient records were reviewed on April 5, 2013. Five client records were required to have a psychosocial evaluation completed by the client's fifth individual session. Client records #1 and 6 did not contain psychosocial evaluations that were completed by the client's fifth individual session.Client #1 was admitted to outpatient treatment on September 20, 2012 and discharged on January 18, 2013. The client's comprehensive treatment was completed on October 20, 2012. Client #1 had a psychosocial evaluation completed on November 15, 2012. The psychosocial evaluation was completed after the comprehensive treatment plan was completed.Client #6 was admitted to outpatient treatment on November 13, 2012. The client's comprehensive treatment was completed on December 14, 2012. Client #2 had a psychosocial evaluation completed on January 21, 2013. The psychosocial was completed after the comprehensive treatment plan was completed.An interview with the Credentialing Coordinator took place on April 5, 2013 confirmed these findings.
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Plan of Correction
Our facility will be in full compliance with this standard by April 12, 2013. We will be reviewing this standard and our related agency policy with all staff at our next staff meeting on May 9, 2013. The proper documentation of clients' psychosocial evaluations will be reviewed and explained. The Clinical Supervisor will also review this area with all counselors in individual supervision as an added measure to insure compliance. |