INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 6, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Centre Counseling Associates 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel files, the facility failed to document an individual training plan in one of one employee records reviewed.
The findings include:
One personnel training record was reviewed for a training plan on July 6, 2015. According to the Staffing Requirements Facility Summary Report, the facility's current training year runs from January 1 to January 1. There was no documentation of a training plan for employee # 1 for the 2014 training year.
Employee #1 was hired as the project director/counselor in July 2003. As of the date of inspection there was no documentation of a training plan for employee #1.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the 9/23/2014 inspection.
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Plan of Correction
The Project Director shall revise the existing policy statement to specifically state that each individual employed by the facility shall adhere to the facilities training policy as per state requirement.The Project Director will review the progress toward fulfilling the training plan on a biannual basis with each employee and make any suggestions or note any deficiencies in said plan.
The dates of these reviews will be the first Monday after January first of each year and the first Monday after June first each year. The reviews will consist of a review of the current requirements for the coming year and the review in June shall be a summary of progress made toward the goal to that date.This will also include the Project Director as being required to adhere to the specified policy.
A final review shall also be added to the plan. It will be held upon the receipt of the documentation for the upcoming licensing inspection that is sent out by the licensing baord
Time Frame 60 days |
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 one of one personnel records reviewed.
The findings include:
One personnel record requiring the documentation of the completion of 25 clock hours of annual training was reviewed on July 6, 2015. The facility failed to document the completion of 25 clock hours of annual training for employee #1.
Employee # 1 was hired in July 2003 as a counselor. The facility training year is from January 1 through January 1. The training year for January 1, 2014 - January 1, 2015 was reviewed. Employee # 1 did not complete any clock hours of annual training for the January 1, 2014 - January 1, 2015 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director acknowledges that because of a clerical error on his part he did not fulfill the training hours in the required time frame by agency policy. The training hours were fulfilled before the specific date required and were fulfilled past the specific date but were not within the January to January period of the training year.
The Project Director has fulfilled more than the required hours before the period and after the specified period for the past inspection.
Special attention will be accorded to this issue in the future and the Policy and Procedure Manual will be reviewed and clarified if necessary.
The Project Director shall include in the Policy and Procedure Manual a system of reviews at specific dates through out the year January first to January first.
The reviews shall be implemented as follows: The Project Director will review the progress toward fulfilling the training plan on a biannual basis with each employee and make any suggestions or note any deficiencies in said plan.
The dates of these reviews will be the first Monday after January first of each year and the first Monday after June first each year. The reviews will consist of a review of the current requirements for the coming year and the review in June shall be a summary of progress made toward the goal to that date. This will also include the Project Director as being required to adhere to the specified policy.
A final review shall also be added to the plan. It will be held upon the receipt of the documentation for the upcoming licensing inspection that is sent out by the licensing board. This entry and the entry pertaining to the training plan shall be added to the manual within 10 days of the submission of the Plan of Correction.
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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all exits from the facility were unobstructed.
The findings include:
A physical plant inspection was conducted on July 6, 2015 at approximately 1:00 PM.
Five portable stationary posts that were each three feet in height were obstructing landing at the bottom of the staircase by suite 10. The obstructed landing leads directly to an exit door.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director contacted the maintenance personal for the building and informed him of the public safety issue. The maintenance person contacted the buildings owner and they agreed it was a safety issue and the items would be stored in more appropriate areas so the building would be in compliance.
The Project Director shall upon his entry to the building ensure that all exits are clear of obstructions. If they are not he will immediately contact the maintenance worker for the building to clear them immediately. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to document any problems encountered on the fire drill logs.
The findings include:
A review of the facility's fire drill records was conducted on July 6, 2015. There was no documentation nor a section to document problems encountered on the fire drill logs for the fire drills conducted from June 2014 - June 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon a review of the fire drill log a revision was made to add a column for the notation of any problems that may have been encountered during the drills. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility's administrative records were reviewed on July 6, 2015 for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services for the previous fiscal year. There was no record of any fiscal audits ever being conducted for the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the inspection the Project director discussed this issue with the Inspector and stated that this issue had been cited in a past year but was corrected and a letter requesting this exemption had be sent and received by the Bureau as part of a the remediation of the previous citation. The Inspector contacted the Project Director that no copy could be found in his records. The Project Director has in his possession 2 copies of said document 1 draft and a revision that was edited by Mr. Ron Young on this requirement. The Project Director will mail hard copies of these original letters to the Bureau within several days of this writing.
The Project Director has submitted an exemption request for this regulation. The documentation for the exception request was mailed to the Department on September 1, 2015.
The facility will await the final decision regarding the exception request and will submit and comply with any additional documentation requested from the Department leading up to the final determination. In the event that the exception request is denied, the facility will....contract for an audit within 60 days of the receipt of the refusal letter. |
709.17(a)(1) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
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Observations
Based on a review of administrative documentation, the facility failed to comply with the directive issued by the Department requiring the facility to develop and implement policies and procedures for the reporting of unusual incidents.
The findings include:
As per the directive within Chapter 709 Subchapter C enacted on 10/18/2014, the facility was required to develop and implement policies and procedures for the reporting of unusual incidents. The facility's administrative records were reviewed for documentation of policies and procedures for the reporting of unusual incidents on 7/6/2015. As of the date of the inspection, the facility has not developed policies and procedures for the reporting of unusual incidents.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director shall review and edit the facilities Policy and Procedure Manual to add a section that specifically addresses the appropriate procedures for documenting and reporting unusual incidents within the facility or as a function of the facility as covered under the requirements of the State Licence. This addition will be added to the P+P Manual.
Time frame 60 Days |