INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 9 & 10, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Chester County Intermediate Unit - CHANGES 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 December 16, 2009.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of training records and personnel files, the facility failed to ensure that one of four staff had received a minimum of 6 hours of HIV/AIDS training and 4 hours of TB/STD training within the time required.
Findings:
On November 9, 2009, a review of four personnel files, including training records, was performed during a site visit. Employee #1 hired on 7/1/07 was required to have completed 6 hours of training in HIV/AIDS and 4 hours of training in TB/STD within two years from hire. There was no documentation that employee #1 had received the mandatory 6 hours of HIV/AIDS and 4 hours of TB/STD training at the time of the site visit.
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Plan of Correction
Due to the fact that Dr. Obrien has no client contact, a letter of exception to this standard will be submitted by December 31, 2009 |
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 staff training records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually.
Findings:
A review of four employee training records was conducted on November 9, 2009 during a site visit. The record of employee # 4 who was hired on 2/19/08 as a counselor, did not contain documentation of the completion of 25 hours of training. The training records of employee #4 documented a total of 17 hours of completed training during the training year 7/08 to 7/09. This was confirmed by the facility director to have been an oversight.
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Plan of Correction
To prevent this oversight in the future, each staff member will review their individual training plan for the year at their mid year evaluation. (December 15th) It will be confirmed at the mid year evaluation, by the direct supervisor, that all required hours of training have been either completed or scheduled. |