INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 22, 2011 through March 24, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Catholic Charities Counseling and Adoption Services, 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 April 21, 2011.
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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 training records and an interview with the facility director, the facility failed to provide documentation of TB/STD training in one of three staff development records, as required by regulation.
The findings include:
Three staff development records were reviewed on March 23, 2011. Three records were required to have documentation of TB/STD training. Per regulation, staff persons shall receive a minimum of 4 hours of TB/STD training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training with the first 2 years of employment. The facility did not provide documentation of TB/STD training in personnel training records # 1.
Employee # 1 is the facility director hired May 19, 2008. TB/STD training was due to be completed no later than May 19, 2010. The facility failed to provide documentation of TB/STD training on March 24, 2011.
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Plan of Correction
By May 31, 2011 the facility director will have completed TB/STD training. The documentation for this training will be placed in the worker's personnel file and be available for review upon the next inspection visit. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, staff development records and interviews with the facility director, the facility failed to document the completion of 12 clock hours of annual training required for facility director in one of one personnel records.
Findings:
Three personnel records were reviewed on March 23, 2011. One personnel record pertained to the facility director. One personnel record required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 2.
Employee # 2 has been the facility director since May 19, 2008. The facility training year is January 1, 2010 through December 31, 2010. Employee # 2 had documentation of seven hours of training for 2010. There was no other documentation of completed training's for the training year ending in December 2010.
An interview with the facility director took place on March 24, 2010 at which time it was confirmed the seven hours of training was the only training documentation available. It was also reported that additional training was completed, however, certificates of completion and/or sign in sheets to verify attendance were not available.
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Plan of Correction
The facility director will attend at least 12 hours of documented training in the next year and documentation of such training will be recorded in the worker's personnel file. |
709.93(a)(3) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(3) Record of services provided.
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Observations
Based on a review of client records the facility failed to document a record of service which includes the type of service and service provider.
Findings:
Four active outpatient client records were reviewed on March 23, 2011. Two of four records reviewed failed to include a record of services with the type and provider of services.
Record # 2 and record # 4 failed to include a record of services with the type and provider of services.
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Plan of Correction
The facility director has already ensured that this worker is currently recording the type of service and a signature for each service provided and documented on each client's Record of Service. This documentation will be monitored during the rest of this fiscal year. |