INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22 through 23, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Daystar Center For Spiritual Recovery 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 February 17, 2009.
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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 the review of employee records, the facility failed to ensure that counselors obtained twenty five hours of training in one out of three personnel records reviewed..
The findings include:
Three counselor's employee records were reviewed on January 23, 2009. All three counselors were required to complete twenty five hours of annual training. Employee # 3 only had five and one half hours of annual training.
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Plan of Correction
Executive Director will insure that Employee#3 completes required hours of training by employee's hire anniversary date of 7/13/2009.
Executive Director will also change tracking of educational hours for the agency from being based on hire date anniversaries to calendar year. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document frequency of treatment in four of four client records.
The findings include:
Six client records were reviewed in January 23, 2009. Treatment plans were required in four of the six client records. The facility did not document frequency in the treatment plans documented in client records # 1, 2, 3 and 4.
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Plan of Correction
Pre-populated field of Treatment plan indicated only type of treatment. Executive Director has replaced the erroneous treatment plans with correct plans where field includes both type and frequency of treatment, and educated staff on the omission of frequency of treatment. Executive Director will monitor for compliance. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information in two of two client records.
The findings include:
Six client records were reviewed on January 23, 2009. Follow-up information was required in two of two client records. The facility did not document follow up in client records # 4 and 6.
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Plan of Correction
Documentation of follow-up with clients #4 and #6 was included in a new book of 2008 client follow-up, and old copies were not removed from book with pre-2008 client follow-up. Executive Director has removed copies without documentation of follow-up and placed instructions to refer to 2008 book for follow-up with 2008 and future clients. |