INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18 through 19, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, NTP Consultants, LLC 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 October 15, 2007.
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Plan of Correction
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709.22(e)(1) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(1) Activities and accomplishments of the preceding year.
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Observations
Based on the review of administrative documentation, the facility failed to document an annual report for the preceding year.
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Plan of Correction
NTP Consultants posted in the local newspaper their income and expenses as well as their status as a sole proprietorship, however was missing the part of the annual report listing their activities and accomplishments. The Director with the help of the Business Manager will create an annual report each year by April 1, listing the agency's activities and accomplishments, income and expenses, and their status as a sole proprietorship (unless a change is made). An annual report in its entirety was drafted for 2006 by the Director and Business Manager on this date. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill record and the facility's approval to use an alternative method to set off fire drills, the facility failed to document that the fire alarm system was in working order.
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Plan of Correction
NTP Consultants conducts monthly fire drills utilizing an alternative method which does not include the use of the actual fire alarm. To this end, the alarm system needs to be tested regularly. On October 5, 2007, ATA Security System who maintains the alarm system in the building tested all devices and found them to be in working order. Alarms were heard throughout the building and a fire drill was conducted at the same time. Documentation from ATA was received of such test.
The agency Director will assume the responsibility of assuring that the alarm system is inspected annually. The Director will correspond with both the building landlord and ATA Security to assure that an annual inspection has occurred. Documentation of such will be acquired and kept on file. |
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 personnel and training records, the facility failed to document the required HIV/AIDS training in one of three records reviewed, #2.
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Plan of Correction
All clinical staff of NTP Consultants will be required to successfully complete HIV/AIDS training within the first year of their employment at our agency. The staff who has not yet completed the training will be signed up for an attend the next available training offered in our area.
Staff #2 was signed up for HIV/AIDS Training November 28, 2007, however she gave her resignation on October 9, 2007 with her last day effective October 30, 2007. |
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 personnel and training records, the facility failed to document the required training hours in one of three records, #2. This employee did not receive any training hours for the previous training year.
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Plan of Correction
As the stated employee #2 had attended only 6 hours of in-classroom education (ethics), all other training hours were received via at-home study courses. The Director will assume the responsibility for assuring that all clinical staff attend in-persons trainings (for a minimum of 25 clock hours) to cover areas of importance to their position to include but are not limited to confidentiality, relapse prevention, PCPC, ethics, cultural awareness, disease of addiction, pharmacology, principals of AA and NA, and substance abuse trends.
Staff #2 will be attending trainings within 90 days to begin accruing training hours for this training year. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of employee records and counselor caseloads, the facility failed to maintain the 35:1 ratio. The client ratio was 63:1.
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Plan of Correction
NTP Consultants will recruit and hire new staff in order to maintain the 35:1 ratio. At this time, NTP Consultants, has hired 2 new part-time counselors working a total of 30 hours. We have maintained the regular staff of a Director/Counselor who works 40 hours and another part-time counselor who work 8 hours per week. NTP Consultants has 60 current clients making our ratio 31:1. |