INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the August 21, 2012 licensure renewal inspection. The follow-up inspection was conducted on March 14, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Innovative Recovery Solutions, 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(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
Compliance with this regulation could not be determined during the plan of correction follow up inspection. Compliance will be determined during the next scheduled inspection. The original deficiency is listed below:
Based on the review of personnel records, the facility failed to document that each counselor shall complete at least 25 clock hours of training annually in one of one personnel record.
The findings include:
Four personnel records were reviewed on August 20-21, 2012. Three personnel records were reviewed as clinical staff. One personnel record reviewed was medical personnel. The training year of January 1- December 31, 2011 was reviewed. The Project/Facility Director's primary job duty is that of a counselor and thus requires 25 clock hours of training annually. The facility did not document 25 clock hours of training for the 2011 training year.
Employee # 1 was hired on September 21, 2009. Employee # 1 completed 20 clock hours of training for the 2011 training year.
The Project/Facility Director was interviewed on August 21, 2012 and confirmed the findings.
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Plan of Correction
Facility Director will monitor staff compliance to ensure completion of required training hours. Facility Director will also monitor on-line trainings to ensure compliance with the Licensing Alert to ensure they are compliant with the training requirements when they are being added to the total completed hours. Monitoring will occur throughout the year as needed. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of facility documentation, the facility failed to make available to the public an annual report for the fiscal year January 1, 2011 to December 31, 2011.
The findings included:
During the onsite inspection of March 14, 2013, the annual report for the fiscal year January 1, 2011 to December 31, 2011 was reviewed. There was no documentation provided that the annual report had been made available to the public as of March 14, 2013.
The Project/Facility Director was interviewed on March 14, 2013 and confirmed the findings.
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Plan of Correction
Facility Director will compile the 2012 Annual Report and provide that documentation to the Board of Driectors for approval. Once approved as indicated by dated signatures of the Board of Directors, Facility Director will place an ad in the newspaper advertising the availability of the report on site. Facility Director will pay for and maintain receipt of payment as well as any proofs provided by the newspaper on site for inspection. This 2012 information and documentation will be completed by 6/30/2013. Facility Director will monitor compliance when auditing the appendices in the Licensing Manual annually. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Compliance with this regulation could not be determined during the plan of correction follow up inspection. Compliance will be determined during the next scheduled inspection. The original deficiency is listed below:
Based on a review of administrative policies and Board meeting minutes the project failed to demonstrate that the project director had assisted the governing body in formulating policy and had presented the information to the governing body at least annually.
The findings included:
The administrative policies and Board meeting minutes from 2011 and 2012 were reviewed on August 20 and 21, 2012. No documentation was presented to support the fact that the Project Director and the governing body collaborated on the formulation of goals and objectives for the fiscal year which began on January 1, 2012.
The Project/Facility Director was interviewed on August 21, 2012 and confirmed the findings.
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Plan of Correction
Project Director shall prepare and provide to the Board of Directors an overall annual report by March 31 of each year and quarterly updated which will be documented in Board Meeting minutes. Compliance with the regulation will be demonstrated during inspections occuring in 2013. |