INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 7-8, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Counseling Center 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(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 the Staffing Requirements Facility Summary Report (SRFSR) and a review of personnel records, the facility failed to ensure that all counselors completed at least 25 clock hours of annual training in one of one personnel records reviewed.
The findings included:
One personnel record which required documentation of 25 clock hours of annual training was reviewed on May 7, 2014. The facility failed to document 25 clock hours of training in personnel record # 4.
Employee # 4 was hired as a counselor on 9/27/10. There were only 17 hours of training documented on the SRFSR form for the July 2012 through June 2013 training year.
The Facility Director confirmed the findings.
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Plan of Correction
We have identified a staff member to oversee the training folders. She will file all certificates and feedback forms. Additionally, she will send quarterly e-mails to all supervisors and their staff to provide an update on the number of completed training hours to date. Supervisors will assist staff with scheduling additional and/or required trainings as needed to make sure all staff have the required number of training hours based on their position.
The clinical Director will be responsible for overseeing this process. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on an observation during the physical plant inspection, the facility failed to ensure that the grounds of the facility were in good repair at all times.
The findings include:
A physical plant inspection was conducted on April 14, 2014. At the time of the inspection, there was a ceiling tile missing directly outside of the Mechanical Room.
The Facility Director confirmed the findings.
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Plan of Correction
The ceiling tile has been replaced.
The Facility Director was responsible for seeing that this task was completed.
The Officer Manager will complete a quarterly building and grounds inspection to ensure all ceiling tiles are in place. The Facility Director is responsible for reviewing these inspection reports and making sure they are completed timely. |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on an observation during the physical plant inspection, the facility failed to ensure that each bathroom was maintained in a functional, clean and sanitary manner.
The findings include:
A physical plant inspection was conducted on April 14, 2014 at approximately (time of day). At the time of the inspection, the following deficiencies were observed:
1.there was a roll of toilet paper resting directly on the floor in front of the toilet in the stall furthest from the entrance in the male client ' s bathroom.
2.the sink in the female employee's bathroom was clogged and would not drain
The facility director confirmed the findings.
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Plan of Correction
The toilet paper holder has been repaired so the toilet paper can be properly stored in the male client bathroom.
The sink in the female employee's bathroom has been unclogged and is now draining properly.
The Facility Director was responsible for overseeing the completion of these tasks and will monitor in the future. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in one of five personnel records reviewed.
The findings include:
Five personnel records requiring documentation that personnel had been trained to perform assigned tasks during emergencies were reviewed on May 7, 2014. Employee #9 was hired on 3/31/14. The training for assigned tasks during emergencies was documented on 4/14/14.
The Facility failed to ensure that the employee had completed emergency training prior to working their first shift.
The Facility Director confirmed the findings.
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Plan of Correction
The new employee orientation documentation has been revised to reflect the completion of emergency preparedness for all new employees within 7 days of hire. This will be reviewed with all staff, including supervisors, during a staff meeting.
The Clinical Director will be responsible for making sure that all new employees receive this training within 7 days of hire and that it is documented on their orientation checklist. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records and an interview with the project director, the facility failed to document annual performance evaluations in three of four records reviewed.
The findings include:
Four personnel records which required documentation of an annual performance evaluation were reviewed on May 7, 2014. The facilty failed to document an annual performance evaluation in personnel records # 1, 3, and 4.
Employee # 1 was hired on 9/10/12. This employee record did not contain documentation of a performance evaluation for 2013.
Employee # 3 was hired 12/12/11. The most recent performance evaluation for this employee was completed on 12/14/12. This employee record did not contain documentation of a performance evaluation for 2013.
Employee # 3 was hired 9/27/10. The most recent performance evaluation for this employee was completed on 9/27/12. This employee record did not contain documentation of a performance evaluation for 2013.
The Facility Director confirmed the findings.
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Plan of Correction
Per our new employee handbook, all employees will receive their annual performance evaluations in December of each year starting in 2014. For the employees found not to have had a performance evaluation in 2013, one will be completed immediately to reflect their performance for that year. They will then have another in Decemeber 2014.
The Executive Director will be responsible for making sure these and all future performance evaluations get completed timely. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on the review of client records, the facility failed to document a monthly random urinalysis in one of five client records reviewed.
The findings include:
Five client records which required documentation of a monthly random urinalysis were reviewed May 7-8, 2014. The facility failed to document a monthly random urinalysis in client record # 16.
Client # 16 was admitted on 9/10/13 and was still an active client at the time of the inspection. The facility failed to document a monthly random urinalysis in this client record during the months of September 2013 and February 2014.
The Project Director confirmed the findings.
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Plan of Correction
During at staff meeting, all staff will be reminded of the need to have at least one random drug screen for all clients enrolled in the "other chemotherapy" program. Each counselor will develop a schedule for their caseload in which they will obtain a random urine sample from each client. The clinical supervisors, during chart audits, will monitor for compliance.
The Clinical Director will be responsible for overseeing the process of both counselors and supervisors. |