INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on October 17 - 18, 2011 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site inspection, Horizon House, Inc. 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(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 the Staffing Requirements Facility Summary Report, the facility failed to ensure that staff persons and volunteers received 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.
The findings include:
On October 18, 2011 the Staffing Requirements Facility Summary Report was reviewed.
Employee # 8 was required to have documentation of HIV/AIDS and TB/STD training.
The facility failed to provide documentation of the required TB/STD training for employee # 8.
Employee # 8 was hired 4/28/2008.
Employee # 8 is a rehab counselor.
HIV/AIDS and TB/STD training was to be completed within the first 2 years of employment, by 4/28/2010.
At the time of review on October 18, 2011, employee # 8 had not received the TB/STD training.
The quality assurance director and the supervisor confirmed the findings.
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Plan of Correction
Employee # 8 is registered for TB/STD training on 12/9/11 at BHTEN. The supervisor will ensure he attends and fulfills his mandatory training requirements. The individual staff annual training plan will be reviewed with the employee. The supervisor will then continue to include and document training requirements in supervision with each staff on a monthly basis. On a quarterly basis, QI staff will monitor to ensure that documented supervision is occurring. |
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 personnel records and a review of the Staffing Requirements Facility Summary Report, it was determined that employee # 3 did not meet the training requirements for counselors.
The findings include:
On October 18, 2011 six personnel records were reviewed.
Employee # 3 was required to complete at least 25 clock hours of training annually.
Employee # 3 failed to complete 25 hours of training.
Employee # 3 was hired 8/6/2007.
Employee # 3 is a drug and alcohol specialist or counselor.
Each counselor shall complete at least 25 clock hours of training annually
A review of employee # 3's personnel record documented 22.5 training hours; in addition, the Staffing Requirements Facility Summary Report completed by the facility on October 14, 2011 documented 22.5 training hours.
The human resource representative and the quality assurance director confirmed the findings.
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Plan of Correction
Employee # 3 has already exceeded her required 25 hours for January 2011 thru December 2011 training year. The Director/ supervisor will ensure she continues to attend and fulfill her mandatory training requirements in the future. The supervisor will then continue to include and document training requirements in supervision with each staff on a monthly basis. The individual staff annual training plan will be reviewed with the employee in supervision.On a quarterly basis, QI staff will monitor to ensure that documented supervisions are occurring. |