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Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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MERCY BEHAVIORAL HEALTH
330 SOUTH 9TH STREET
PITTSBURGH, PA 15203

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Survey conducted on 10/23/2009

INITIAL COMMENTS
 
This report is a result of an on-site licensure renewal inspection conducted on October 22 - 23, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mercy Behavioral Health 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 November 20, 2009.
 
Plan of Correction

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.
Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of two personnel records.



The findings include:



Six personnel records were reviewed on October 14, 2009 and October 22, 2009. Two personnel records pertained to counselors. Two personnel records required the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 6.



Employee # 6 was hired on August 1, 2006. The facility training year is from July through June. Employee # 6 only completed 22 clock hours of annual training from July 2008 through June 2009.



The facility director confirmed that employee # 6 completed only 22 clock hours of annual training from July 2008 through June 2009. The facility director reported the counselor had been on medical leave.
 
Plan of Correction
Facility Director will review training hour requirements with project staff in staff meetings throughout the project year and individually in supervision, to make sure project staff are achieving the required training hours

 
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