INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the April 30, 2009 licensure renewal inspection. The follow-up inspection was conducted on August 24, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Home Nursing Agency Community Services 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 September 25, 2009.
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Plan of Correction
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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 the training records and discussion with the Facility Director and Clinical Supervisor, the facility failed to document the 25 hours of required training for the 2008-2009 training year for one counselor.
The findings include:
The training record was requested to be submitted to the Division on August 26, 2009 in order to determine if the training hours were completed for the 2008-2009 training year. The training was reviewed on August 27, 2009. Twenty-five training hours are required for the counselor records requested. The Facility Director and Clinical Supervisor each stated the counselor had the required hours of training, but the training hours documented only 18 hours of training for the 2008-2009 training year.
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Plan of Correction
The Clinical Services Manager has confirmed that staff has attended 25 hours of training. Additional CPR Certification for 3 hours has been faxed to auditor, Jacquelyn Fahlor week of 9/6/09. Additional 6 hour certificate from co-occurring disorder training will be obtained from provider and faxed by week close of 9/16/09. Employee will be disciplined. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of the client records during the plan of correction follow-up visit on August 24, 2009, the facility failed to document treatment plan updates in one of one applicable record.
The findings include:
Five client records were reviewed on August 24, 2009. Treatment plan updates were required in one record. The facility did not document treatment plan updates in one of one record. Treatment plan updates were due May 29, 2009 and June 29, 2009, but there was no documentation of either treatment plan update in client record #2.
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Plan of Correction
The Clinical Services Manager has met with staff and developed a weekly schedule to review completion of required documentation for level of care. Clinical Services Manager is ensuring that treatment plan updates are completed by the due date as required by licensure. Disciplinary action will be taken if this requirement is not met. |