INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on March3, 2015 through March 4, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run, Inc. 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report forms for all facilities within the drug and alcohol treatment project, the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.The findings include:The Staffing Requirements Facility Summary Report forms for the drug and alcohol treatment project's were reviewed on March 2, 2015. The project employs a total of 106 full-time counselors and counselor assistants. This number of full-time counselors and counselor assistants would require a minimum of 13 full-time clinical supervisors. The project currently employs 8 full-time clinical supervisors, as of March 2, 2015.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Quality Management, along with the Executive Director, will ensure there is one full-time clinical supervisor for every eight full-time counselors and counselor assistants. Caseloads will be redistributed by July 1, 2015 so that clinical supervisors who carry a caseload fall within the guidelines of chapter 704.6. Facility directors and clinical supervisors will be re-educated by the Quality Management Department on permissible case load sizes for each level of care.
Compliance will be accomplished by the facility director, along with the clinical supervisor(s), monitoring the number of full-time counselors vs. clinical supervisors on a quarterly basis.
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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 Staffing Requirements Facility Summary Report (SRFSR) and the personnel records, the facility failed to obtain and document the completion of 25 clock hours of annual training required for counselors in one of fourteen personnel records reviewed.The findings include:The SRFSR was reviewed on February 2, 2015 and re-reviewed on March 3, 2015. Fourteen personnel records were reviewed on March 3, 2015, but only five personnel records pertained to counselors. However, only two personnel records were required to have the regulated training hours based on their hire dates. The facility failed to ensure that the counselors obtained and documented at least 25 clock hours of annual training in employee record #13.Employee #13 was hired into the project on December 30, 2007 and promoted to counselor status on September 20, 2009. The facility's training year was from January 1, 2014 through December 31, 2014. The facility only had 15.5 clock hours documented for the 2014 training year.These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisors will be responsible for assuring that counselors complete a minimum of 25 clock hours of training annually. Clinical supervisors will be re-educated on this requirement by QM. The QM department at Allenwood will send out a quarterly report that lists staff and the trainings they have taken. Clinical supervisors will be responsible for assuring that staff have the appropriate number of training hours. The training hour report will be reviewed with counselors in supervision sessions. |