INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 28 through 29, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on October 5, 2006.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
The project had more than eight full time counselors (10) and lacked a full time clinical supervisor. The current clinical supervisor also serves as the facility director.
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Plan of Correction
Our project is in full compliance with this standard as of today 9/20/06. We mistakenly identified our full time clinical supervisor as also being the facility director on the "Staffing Requirements Facility Summary Report." This mistake was discovered during the on-site licensure renewal inspection. In actuality, our Project Director is also the Facility Director and our Clinical Supervisor is indeed full time. In the future we will correctly identify these positions on the report. |
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
Employee # 7 did not receive 12 of 12 required training hours for the 2005 training year.
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Plan of Correction
Our project will be in full compliance with this standard by 6/30/07, which is the end of our current training year. By that date employee #7 will have received 12 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. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
The exit from the trailer to the front of the building was obstructed by a ladder, Abel, and bread crates.
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Plan of Correction
The project was in full compliance with this standard by 9/26/06. The ladder, which was there for repairs to an air conditioner that day, has already been removed by the maintenance man who had been using it. The table and bread crates that were leaning against the wall were put out with the trash by an employee and will be removed by borough employees on trash pick up day, which will next be 9/26/06. It should be noted that this is an optional exit from our building as there are two other exits in place on this floor. Although it was suggested that we could simply not specify this as an exit, we would prefer to leave that option available in case of an emergency. In the future we will not allow any items to obstruct this exit. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
The same exit was used for fire drills conducted January 2006 through August 2006.
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Plan of Correction
Our project is in full compliance with this standard as of today 9/20/06. During the 9/14/06 staff meeting, this standard was reviewed with all staff members. The need to use different exits during a fire drill was specifically reviewed. Last evening, 9/19/06, a fire drill was conducted and documented in which a different exit route was used. Additionally, a reminder sheet regarding the necessary parts to a fire drill has been posted along with the fire drill log to help with future fire drills. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
The times of the fire drills were not varied.
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Plan of Correction
Our project is in full compliance with this standard as of today 9/20/06. During the 9/14/06 staff meeting, this standard was reviewed with all staff members. The need to vary the times of fire drills was specifically reviewed. Last evening, 9/19/06, a fire drill was conducted at a different time than the other fire drills had been. Additionally, a reminder sheet regarding the necessary parts to a fire drill has been posted along with the fire drill log to help with future fire drills. |
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
Work performance evaluations were not completed in three of three personnel records, # 1, 2 and 7
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Plan of Correction
Our facility will be in full compliance with this standard by 9/30/06. The supervisor had failed to complete the work performance evaluation in a timely manner for employee #2. Employees #1 and #7, as co-owners of the business, complete work performance evaluations on one another and had failed to do so in a timely manner, the last ones being completed in June of 2005. All of these work performance evaluations will be completed by 9/30/06 and be filed in their personnel files. |
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
Psychosocial evaluations were missing in two of eleven client records reviewed, #6 and 8.
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Plan of Correction
Our facility will be in full compliance with this standard as of 10/31/2006. This standard and our agency policy relative to this standard will be reviewed with all counselors at our next staff meeting on 10/12/06. The proper documentation of proposed type of support services will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance. It should be noted that the psychosocial evaluation for client record #6 had been misfiled and was located the day after the on site visit. It is now properly filed in the client's record. The psychosocial evaluation for client record #8 was only partially complete because the client had attended only two appointments with the clinician. The client failed to continue with treatment so the documentation could not be completed. The portion of the psychosocial evaluation that is completed is filed in this client's closed record. |