INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 9, 2010 and September 10, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital Outpatient Treatment Program 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 October 11, 2010.
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Plan of Correction
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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on survey results, interviews and a review of staff development records the outpatient facility failed to document that the counselor assistants were working toward obtaining the necessary qualifications for the position of counselor.
Finding:
On September 9, 2010 and September 10, 2010 staff development records were reviewed to determine that the two counselor assistants were working toward obtaining the necessary qualifications for the position of counselor. The facility employs two counselor assistants. Both counselor assistants were required to work toward obtaining the necessary qualifications for the position of counselor during the January 1, 2009 through December 31, 2009 staff development year. Both counselor assistant records failed to include documentation of college credits or certified CAC training hours for the 2009 staff development year.
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Plan of Correction
Assistant Counselor submitted application to PCB f9or AACI with all required paperwork. Clinical Supervisor will monitor status. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on survey results, interviews and a review of staff development records the facility failed to assure that each counselor assistant completed at least 30 hours of training annually.
Findings:
The facility employs two counselor assistants. One of two counselor assistants was required to obtain 30 hours of training annually. One of one counselor assistants failed to obtain 30 hours of training for the January 1, 2009 through December 31, 2009 staff development year.
Employee # 5 was hired as a counselor assistant in August 2008. The counselor assistant was required to obtain 30 hours of training for 2009. Twenty five hours of training was documented in the record reviewed on September 9, 2010. Employee # 5 is five hours short of the annual training requirement.
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Plan of Correction
Employee reminded of State mandated training hours required for Counselor Assistant and advised this is their responsibility to monitor. Clinical Supervisor will monitor employee's compliance with monthly reviews of educational requirements. |
705.22 (1) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on survey results and a physical plant tour, the nonresidential facility failed to maintain the group room on the first floor.
Findings:
A tour of the physical plant on September 8, 2010 revealed that the carpeting in the group room on the first floor was torn, worn and stained.
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Plan of Correction
The carpeting will be replaced with new carpeting by 11/15/10. The Facilities Director will assure compliance. |
711.14(b)(5) LICENSURE Subchapter B.Approval Procedures.Restrictions
711.14. Restrictions on certificate of compliance.
(b) Utilizing appropriate Department forms, the holder of a certificate shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on survey results, interviews and a physical plant tour the non-hospital outpatient maintenance unit failed to notify the Department of a change in authorized capacity.
Findings:
A review of the daily census report with the facility director on September 9, 2010 revealed that there were 163 active patients during the scheduled survey. The authorized capacity for the outpatient maintenance is 160. The outpatient maintenance unit is over capacity by three patients.
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Plan of Correction
Capacity was reflective of three (3) individuals who are currently incarcerated and a few pending transfers. As of 10/1/10, transfers have since been completed and therefore, current census is at 151. Clinical Supervisor will montiro census for compliance. |
711.92(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on survey results, interviews and a review of patient records, the outpatient facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan.
Findings:
Eight patient records were reviewed on September 9, 2010. Eight of eight records failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan.
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Plan of Correction
Staff in-service on proper documentation and the importance of documenting type and frequency of treatment on 9/20/10. The Clinical Supervisor will review five (5) charts weekly for compliance for a period of six (6) months. |