INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 30, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System - Return Program 1 & 2 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 November 26, 2007.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of training records, the facility failed to document feedback on completed training for the January 2006 to December 2006 training year in five of five records reviewed, #1, 2, 3, 4 and 5.
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Plan of Correction
Training feedback forms were initiated in Januray 2007 and will be available for all training sessions during training year January-December 2007 and beyond. The Program Director and or his disegnee will monitor for compliance. |
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 training records, the facility failed to document the minimum required number of training hours in one of two records reviewed, #5. Employee #5 did not have any training hours for the 2006 training year.
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Plan of Correction
The Program Director will monitor the training record on a quarterly basis to ensure that all staff obtain the required number of training hours. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill record, the facility failed to document which exits were used during the fire drills for the past nine months.
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Plan of Correction
In service training on the accurate completion of fire drill logs will be provided by the saftey office to all staff on or before December 31, 2007. These logs winclude the designation of the exit route used during the drill asn will document alternate routes. The Program Director will monitor on a monthly basis the accurate completion of the form. |
711.52(d) LICENSURE Tx Plan Update
711.52. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document an assessment of the client's progress in relationship to the stated goals of the treatment plans in three of four records reviewed, #3, 4 and 5.
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Plan of Correction
Inservice training regarding treatment planning will be provided by the education department on or before February 1, 2008. Effective immediately increased clinical supervision will be provided by the Program Director who will monitor the documentation of meausrable goals and objectives. |