INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 10 -11, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Esper Treatment Center 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 September 9, 2010.
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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
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 seven personnel records reviewed.
The findings include:
Eight personnel records were reviewed on August 10, 2010. Seven personnel records were required to include documentation of training hours. Five personnel records represented counselors and were required to include documentation of the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 4.
Employee # 4 was hired in August, 2006. The facility training year is from July through June. The training year for July 2009 through June 2010 was reviewed. Employee # 4 only completed 14.5 clock hours of annual training in 2009-2010.
The Director confirmed on August 10, 2010 that the counselor did not have the 25 clock hours of training for the 2009-2010 training year.
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Plan of Correction
The clinical director already has an instrument to track trainig hours. She will review all training hours quarterly and update tracker as trainings are completed. |
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 the administrative information on August 11, 2010, the facility failed to provide an annual audit for the 2008-2009 fiscal year.
The findings include:
Per the director, the 2008-2009 annual audit is currently in process. An extension for completion of this audit was received, and it will be completed within a month. The 2008-2009 audit was not completed as of the licensing inspection on August 10-11, 2010.
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Plan of Correction
The Esper Treatment Center is an S corporation. The Esper Treatment Center does reatin the services of two different accouting firms. One is specifically for taxes and one performs the audit. The audit for calender year 2009 is in process and the firm had some delays but I have correspondence from the CPA stating that the audit for 2009 will be completed in 2 weeks. The Esper Treatment Center will ensure that the audit is completed per the state regulations. The Project Director will meet with the accouting firm in the future to ensure that the audit is done within the time paramenters. |