INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 9 through 14, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, T. W. Ponessa and Associates Counseling Services 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 and a plan of correction is due on October 12, 2007.
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Plan of Correction
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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 employee training records, the facility failed to ensure that one of three employees completed TB/STD training within the required time frame, #1.
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Plan of Correction
The identified employee is scheduled for TB/STD trainig 11/14/07. The Quarterly Reports will serve as monitoring device to ensure mandated trainings are comleted in the required time frame.The Facility Director will continue to record in the Quarterly Report all trainings completed by the employees associated with the D&A component. Using the employee yearly training plan as reference, the Program Director in tandem with Facility Director will compare information monitor and ensure the required trainings are completed in the identified time frame. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of employee training records, the facility failed to ensure that one of three employees completed the received 12 hours of training, #1. Employee #1 received only 6 training hours.
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Plan of Correction
The identified employee is scheduled for a 6hour administrative training on 10/26/07 and a TB/STD training 11/14/07.The written Quarterly Reports will serve as monitoring device to ensure all employees associated with the D&A component recieve/complete the designated amount of mandated yearly trainings hours. The Facility Director will continue to record in the Quarterly Report all trainings completed by said employees. Using the employee yearly training plan as reference, the Program Director in tandem with Facility Director will compare information to monitor and ensure the required amount of yearly training hours are completed. |
709.93(a)(2) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(2) Medication records.
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Observations
Based on a September 10, 2007 review of client records, the facility failed to document medication records in two of three client records. Client record # 1 was missing dosage of medication and record #3 was missing frequency of medication.
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Plan of Correction
In the 9/10/07 regularly scheduled weekly supervision,Facility Director reviewed with Clinician the chart deficiencies.Referenced regulations, P&P's, and specifically stated form instructions of mandated medication documentation.Revisited alternative methods and procedures to obtain required informtaion in lieu of client self-report.For next 3months, Facilitiy Director will closely monitor the medication section of the BPS summary to ensure appropriate medication documentation is recorded.Review of findings will be discussed at weekly supervision. |