INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 23 - 24, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection,RHJ Medical Center Inc./Vandergrift 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 March 18, 2011.
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Plan of Correction
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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 administrative policies and procedures, and an interview with the project director on February 15, 2011, the facility failed to complete the 2009 audit by the end of the project's fiscal year, as required by regulation.
The findings include:
A review of administrative policies and procedures, and an interview with the project director was conducted on February 15, 2011. Per regulation, 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. The project's fiscal year is from January through December. The project's audit for January 1, 2009 through December 31, 2009 was due at the time of the onsite inspection. The project failed to document the completion of an annual audit for the 2009 fiscal year.
On February 15, 2011, the project director confirmed the 2009 audit had not been completed.
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Plan of Correction
The project director will submit a written request approved by the board of directors for an exception to this regulation so that we may fulfill the intent of the regulation without encurring the expense of a full audit.
If the exception request is denied we will have an independant public accountant complete a full audit of all financial activity for the organization for 2010. |
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 two personnel records reviewed.
The findings include:
Eight personnel records were reviewed on February 23, 2011. Two personnel records 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 # 7.
Employee # 7 was hired on April 7, 2008. The facility training year is from January through December. The training year for January 2010 to December 2010 was reviewed. Employee # 7 only documented 16.5 clock hours of annual training for 2010.
The Project Director confirmed that the counselor did not have the 25 clock hours of training documented for the 2010 training year.
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Plan of Correction
The project director will meet with staff member to remind him of the importance of signing in for and completing paperwork required to properly document attendance at all staff trainings.
The project director will also meet with the clinical supervisor to direct her to review all staff training documentation to ensure that all staff in attendance have completed the required documentation. The clinical supervisor will also remind staff of the importance of completing this documentation on an ongoing basis as necessary so that we are able to maintain compliance with this regulation.
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