INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 20, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County 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 personnel records, the facility failed to provide documentation of 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 in one of one personnel record.
The findings include:
Five personnel records were reviewed on December 20, 2012. One personal record was reviewed for compliance with the 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. Per regulation, 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. There was no documentation of the required training in personnel record # 5.
Employee # 5 was hired as a secretary on March 7, 2008. The 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 was to be completed by March 7, 2010. There was no documentation the training had been completed.
The facility director and compliance officer were interviewed on December 19, 2012 and confirmed the findings.
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Plan of Correction
All personnel who have not received the training on communicable Diseases will be scheduled for the next available, accessible training provided. It appears the next scheduled is for May,2013. We will monitor the training site for additional dates.
In the future, new hires in the support staff departments will be scheduled to attend the next available trainings as part of their required orientation.
It is the responsibility of the Compliance Officer and the Clinical Supervisor to monitor compliance.
Target is June 30,2013. |
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, the facility failed to document the completion of 25 clock hours of annual training required for counselors in two of two personnel records.
The findings include:
Five personnel records were reviewed on December 20, 2012. Two personnel records pertained to counselors. Two personnel records required the completion of 25 clock hours of annual training. The 2011/2012 training year was reviewed. The facility failed to document 25 clock hours of annual training in personnel records # 3 and 4.
Employee # 3 was hired on June 23, 2008. There was only 12 clock hours of annual training documented for the 2011/2012 training year.
Employee # 4 was hired on June 23, 2009. There was only 10 clock hours of annual training documented for the 2011/2012 training year.
The facility director and compliance officer were interviewed on December 20, 2012 and confirmed the findings.
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Plan of Correction
Review of the current training year indicates that training is being acquired at a reasonable pase. The training hours will be met for this fiscal year.
Clinical Supervisor and therapists are responsible for monitoring compliance.
Target date is June 30,2013. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records, the client handbook and the physical plant inspection, the facility failed to provide documentation that clients were informed of their rights in three of three client records.
The findings include:
Three client records and the client handbook were reviewed on December 20, 2012. The physical plant inspection was conducted on December 20, 2012. Three client records required documentation that the client was informed of their rights. There was no documentation that the clients were informed that they had (3) the right to inspect his own records; that the project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client and that the reasons for removing sections shall be documented and kept on file. (4) The client has the right to appeal a decision limiting access to his records to the project director. (5) The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records and (6) The client has the right to submit rebuttal data or memoranda to his own records in client records # 1, 2 and 3.
The facility director and compliance officer were interviewed on December 20 and did not dispute the findings.
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Plan of Correction
In response to this regulation, the Clients' rights, as stated in the regulations, and included in our Policy and Procedure manual will be included in the client orientation packet. The policy will be provided in its entirity.
Compliance Officer is responsible for adding the policy to the packet.
Target date for completion is January 18,2013. |