INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 15-16, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, BGI Of Brandywine, 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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704.11(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 the facility's staffing requirements facility summary report (SRFSR) and discussion with facility staff, the facility failed to provide documentation of individual training plans by April 2014. This was not documented for 37 of 114 staff listed on the SRFSR.
The findings include:
The facility's staffing requirements summary report, SRFSR, was reviewed on May 15, 2014. Individual training plans were required for all staff by April 30, 2014.
Three counseling staff did not have a current training plan as of the date of the inspection. Thirty four medical and support staff did not have a current training plan as of the date of the inspection.
The findings were reviewed with the Director of Quality Management and were not disputed.
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Plan of Correction
All missing training plans will be completed by the employee and submitted to the Quality Management department within the next 30 days. Prior to December 1, 2014 the Quality Managment team will distribute the annual training plan form for the following calendar year. Each department manager will be responsible for collecting all training plans and returning them to the QM department by January 1, 2015. The department supervisors are responsible to ensure these plans are completed and submitted by the corresponding due dates. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the facility's staffing requirements facility summary report (SRFSR), the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum as per the regulatory requirements for four of thirty staff who required the training at the time of the inspection.
The findings include:
The facility's SRFSR form signed by the facility director on May 16, 2014 was reviewed on May 15, 2014. The form listed four staff as not having completed the mandatory training within the regulatory time frames
Employee # 21, a support staff person, was hired on August 9, 2011. Employee # 21 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by August 9, 2013. The training was not documented as of the date of the inspection.
Employee # 14, a counselor, was hired on January 4, 2013. Employee # 14 was required to obtain 6 hours of HIV/AIDS training by January 4, 2014. The training was not documented as of the date of the inspection.
Employee # 15, a counselor, was hired on January 3, 2013. Employee # 15 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by January 3, 2014. The training was not documented as of the date of the inspection.
Employee # 16, a counselor, was hired on March 11, 2013. Employee # 16 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by March 11, 2014. The training was not documented as of the date of the inspection.
The findings were reviewed with the Director of Quality Management and were not disputed.
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Plan of Correction
The four identified staff not having the required HIV/AIDS and TB/STD will complete the required training hours within the next 60 days. Department managers will ensure completion of these trainings with compliance monitored by the Human Resources department. The QM Department will distribute a Staff Roster quarterly so Department Managers can ensure staff are completing trainings in compliance with state regulations. |
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 staff development records listed on the staffing requirements facility summary report, the facility failed to document the completion of 25 clock hours of annual training for counselors in three of four counselor records reviewed.
The findings included:
Four counselor training records were reviewed on May 15, 2014. Four counselor records were required to include documentation of the completion of 25 clock hours of annual training. The facility failed to document at least 25 clock hours of annual training for counselors # 14, 17 and 18.
The findings were reviewed with the Director of Quality Management and were not disputed.
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Plan of Correction
A spreadsheet will be created within the next 30 days to track required annual training hours for 2014 for clinical staff. This spreadsheet will be updated monthly by the Clinical Director and monitored by Clinical Supervisors to ensure compliance with the required 25 hours of annual training. The training hour spreadsheet will be reviewed with counselors during supervision sessions. Clinical supervisors will be responsible for assuring that staff have the appropriate number of training hours. |