INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on April 10, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Familylinks, 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
The facility failed to ensure counselors completed at least 25 clock hours of training annually in one of one personnel record.
Six personnel records were reviewed. One was reviewed for the required training hours.
Employee # 3 required 25 hours of training for the January to December 2019 training year. There were only 21.5 hours of training documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.11. Staff development program. Observation #0083: Training requirements for counselors. Program Manager met with Shady Location Counselors via phone conversations on May 6, 2020 to review that each should complete 25 clock hours of training annually in areas of client recordkeeping, Confidentiality, Pharmacology, Treatment planning. Counseling techniques, Drug and alcohol assessment, Codependency, Adult Children of Alcoholics issues, Disease of addiction, Aftercare planning, Principles of Alcoholics Anonymous and Narcotics Anonymous, Ethics, Substance abuse trends, Interaction of addiction and mental illness, Cultural awareness, Sexual harassment, Developmental psychology and Relapse prevention. Each Therapist will complete 25 hours training each year starting January - December annually. Program Manager will oversee that each Counselor has a training plan developed with the goal of 25 hours appropriate documented training per reviewed topics. Program Manager will review on going documented training during individual supervisions.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The facility failed to document an annual financial audit.
Administrative documentation was reviewed. The facility did not document an annual audit for the fiscal year 2018/2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.25 LICENSURE
Fiscal Management:
#0169 The Program Manager reviewed findings on April 10, 2020 with Familylinks Director of Behavioral Health and Familylinks Financial Controller that the agency must obtain the services of an independent certified public accountant for an annual financial audit of activities associated with Familylinks drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities must have been conducted and finalized by December of 2019. Familylinks Financial Controller will provide Program Manager with cover page of the final version of audit reviewed and signed by the certified public accountant for submission for review for licensing inspection. Program Manager reviewed with Familylinks Financial Controller that this audit must be completed and signed off on by independent certified public accountant no later than the last day of December each fiscal Year.
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