INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 25, 2013 to September 26, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Harbor Counseling 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(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 personnel and training records, the facility failed to provide documentation of HIV/AIDS training in two of two records reviewed.
The findings include:
Six personnel records were reviewed during the onsite licensure renewal inspection. Per regulation, staff persons shall receive a minimum of four hours of TB/STD training and six hours of HIV/AIDS training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training within the first two years of employment.
Employee #3 was hired by the facility on 1/24/2011 as a counselor. This employee was required to obtain HIV/AIDS and TB/STD training by 1/24/2012. The personnel record documented training on 5/17/2013.
Employee #5 was hired on 1/24/2011 as a counselor assistant and is currently employed as a Certified Recovery Specialist. The employee was required to obtain HIV/AIDS and TB/STD training by 1/24/2013. There was no documentation of the training at the time of the inspection.
The findings were reviewed and confirmed by the Facility Director.
The findings were reviewed with the Facility Director and confirmed.
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Plan of Correction
One of the employees found not to have the HIV/AIDS and TB/STD trainings completed the trainings on 10/3/13, and documentation has been included in her personnel/training file. The second employee needing the trainings has the course materials, is working on them, and will have them completed and documented by 10/31/13. The facility has a new Clinical Supervisor as of 9/1/13, and she has been assigned responsibility (under Program Director's supervision) for monitoring and insuring compliance with staff development requirements. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the facilities staff schedule work hours and the Fist Aid and CPR certification cards, the facility failed to provide a sufficient number of staff persons trained in CPR and First Aid during the project's hours of operation.
The findings include:
The CPR certification cards and First Aid certification cards were reviewed on September 25, 2013. All CPR/First Aid certification cards had a recommended renewal date of 7/2013. There were no staff persons with current training in CPR/First Aid at the time of the inspection.
The findings were reviewed and confirmed by the Facility Director.
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Plan of Correction
On-site CPR/First Aid certification training was conducted for all Harbor Counseling staff on 10/30/13. The training was provided by appropriate Laurel Health System/Soldiers and Sailors Memorial Hospital staff. Program Director verified that documentation of the training and staff certifications are included in all personnel/training files. Business Manager has already set up in Outlook a scheduled reminder prior to the two-year expiration of current certification to ensure timely scheduling of CPR/First Aid training. Additionally, Business Manager has established an Excel spreadsheet to track staff training needs, and has added CPR/First Aid training to the tracking information. This document is used yearly by the Program Director as part of the staff training plan process. |
704.11(e)(1) LICENSURE Trng Req-Clinical Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(1) Subject areas for training shall be selected according to the training plan for each individual.
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Observations
Based on a review of personnel and training records, the facility failed to provide documentation of an individual training plan in one of one record reviewed.
The findings include:
Five personnel training records were reviewed during the onsite licensure renewal inspection. Employee # 2 was promoted to the clinical supervisor position on September 1, 2013. An individual training plan had been developed for the 2013 to 2014 training year based on the employee's previous position. An individual training plan had not been developed based on the current position as of the date of the onsite inspection.
The findings were reviewed with the Facility Director and confirmed.
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Plan of Correction
Note that the new Clinical Supervisor had not assumed position until 9/1/13, less than 30 days prior to the survey exit date. Program Director had already been meeting with new Clinical Supervisor for required weekly supervision sessions. Part of the discussions had been about training needs and the identification of appropriate trainings. A full individual training plan was developed and documented by the Program Director by 10/31/13. Program Director has had a cover page added to every Job Description template notifying of the need to immediately develop an appropriate training plan for every new hire or any employee changing position at the same time that the Job Description is signed. This will ensure that the oversight does not occur again. |
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 and training records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that each counselor completed 25 clock hours of annual training in two of eight record reviewed.
The findings include:
The Staffing Requirements Facility Summary Report was reviewed during the onsite licensure renewal inspection.
Employee # 4 was listed as having had 16.5 hours of training during the previous training year. The required training was not met.
Employee # 7 was listed as having had 17 hours of training during the previous training year. The required training was not met.
The findings were reviewed with the Facility Director and confirmed.
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Plan of Correction
Program Director reviewed the regulatory standard with all staff during two staff meetings in October 2013, and addressed the standard requirements individually with the two employees who had not gotten their required training hours (including a review of their current individual staff development plans). The Program Director has also discussed the standard with the new Clinical Supervisor, and assigned her responsibility for monitoring and documenting compliance with the standard for all staff. Furthermore, the Program Director has instituted formal monthly to bi-monthly in-house staff training sessions to increase assurance that all staff receive minimum required training hours. |