INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 11-12, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Abstinent Living at the Turning Point at Washington, 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
Based on the review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually in one of one personnel record.
The findings include:
The 2012-2013 training year was reviewed during this inspection.
Four personnel records were reviewed on March 11-12, 2014. Two personnel records were reviewed as counselors. One counselor was required to complete at least 25 clock hours of annual training for the 2012/2013 training year. The facility failed to ensure that employee # 3 completed at least 25 clock hours of annual training for the 2012/2013 training year.
Employee # 3 was hired as a counselor on January 24, 2006 and was required to complete at least 25 clock hours of annual training in 2012/2013. The record contained documentation of 22 clock hours of annual training for 2012/2013.
The Project/Facility Director was interviewed on March 12, 2014 and confirmed the findings.
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Plan of Correction
The operations manager confirms that Employee #3 did fail to complete the required training hours. The requirement has been reviewed with all applicable staff, in their clinical supervision and staff meetings. They have all been instructed that they must have 25 hours of education each year, and that the training year runs from July - June, and have been notified that the fax trainings will not be counted. The operations manager and business manager will monitor the training hours as completed to ensure compliance. This will be overseen by the project director. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the annual report and administrative documentation, the facility failed to make the 2012-2013 annual report available to the public.
The findings include:
Administrative documentation, including the 2012-2013 annual report, was reviewed on March 11, 2014. The facility was required to make the annual report available to the public. The facility failed to make the 2012-2013 annual report available to the public as of March 11, 2014.
The Project/Facility Director was interviewed on March 12, 2014 and confirmed that the annual report had not been made available to the public as of March 12, 2014.
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Plan of Correction
The operations manager confirms that the 2012-2013 annual report was made available once the 2012-2013 audit was completed. The operations manager confirms that this was done beyond the end of the fiscal year. The operations manager and business manager will ensure that the annual report will be made available to the public at the end of the fiscal year. They have communicated this requirement with the accountant and auditor, and will ensure that future annual reports are filed within the time requirements to ensure compliance. This will be overseen by the project director. |