INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16 through 16, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Colonial House Outpatient 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 May 16, 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 the review of employee records one out of one counselors failed to complete twenty-five hours of annual training.
The findings include:
Four counselor's employee records were reviewed on April 15, 2009. Twenty-five training hours were required in one of one employee records. The facility failed to ensure that employee # 3 received twenty-five annual training hours as this individual only had fifteen hours.
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Plan of Correction
A training calendar will be presented in Director's Office. The Director will be responsible to ensure that all staff will obtain the proprer number of training hours. The Director of Outpatient will keep track of the hours through the calendar and training evaluations and receipt of certificates. The calendar will include the number of hours needed and trainings that are being offered throughout the year in enough time for the counselor to complete the registration. As the tranings are completed the training hours will be deducted from that persons name. Director will review staff training needs on a monthly basis. It will then be reviewed in staff meeting on a monthly basis. Counselor #3 will be attending 2 trainings by the end of May, 2009 |
705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on a physical plant walk through inspection, the facility failed to ensure that the second floor of the facility has a second means of egress.
The findings include:
The physical plant walk through inspection occurred on April 16, 2009. The facility currently only has one exit from the second floor.
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Plan of Correction
We are having a fire escape installed. The contractor has been contacted and it is being fabricated at this time. THe fire escape will be installed by June 30th, 2009. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultation notes in one of three client records.
The findings include:
Eight client records were reviewed on April 16, 2009. Case consultation notes were required in one of three client records. The facility failed to document case consultation notes in client record # 3.
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Plan of Correction
A new form has been designed and recently implemented to assisst the counselors in completion of documentation of case consults, etc. This form is at the beignning of the chart and as the document is completed the item is checked off. We are also going to sart peer reviews amongwst the clicical team bi-weekly. The Director of Outpatient Services will be responisble through quality control 2x month to make sure that the documentation is correct |