INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 11, 2013 to September 12, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Spring-Ford Counseling 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:
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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 a review of personnel records, the facility failed to ensure that each counselor completed 25 clock hours of required training in one of two personnel records reviewed.
The findings include:
From September 11, 2013 to September 12, 2013, two personnel records requiring documentation of 25 clock hours of training were reviewed. The facility failed to provide documentation of 25 clock hours of training in one of two personnel records reviewed, specifically, personnel record # 2.
Employee # 2 is a counselor and was hired November 3, 2011. Employee # 2 was required to complete 25 clock hours of annual training hours by June 30, 2013. However, personnel record # 2 only had documentation of 24.5 clock hours of annual training for the July 1, 2012 to June 30, 2013 training year of September 12, 2013.
The findings were confirmed during an interview with the project director on September 12, 2013 at approximately 12:00 P.M.
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Plan of Correction
By November 1, 2013, Executive Director shall remind all staff on mandatory 25 clock hours for training per fiscal year. Executive Director will monitor annual training required hours for each counselor and will ensure training hours are completed by 6/30/2014. Executive Director will review training hours mid year (January) and give each staff member number of training hours obtained and number of training hours still needed before end of fiscal year. |
705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on observations on September 12, 2013, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A physical plant inspection was conducted on September 12, 2013. It was observed during the inspection at approximately 11:39 A.M., that there is a dumpster located in a parking lot of a business next to the facility. The facility shares the dumpster with the business. The dumpster had trash filled to the top, was overflowing with trash, and was not covered with lids.
The findings were confirmed during an interview with the project director on September 12, 2013 at approximately 11:42 A.M.
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Plan of Correction
On September 26, 2013, Executive Director discussed dumster lid closing, cleanliness with Landlord. Executive Director requested that Landlord inform all tenants who share dumpster to be mindful of closing lid after use and have all trash inside of container. Executive Director and Office Administrator shall view dumpster 2x per day - morning and evening to ensure lid is closed. Executive Director shall request landlord to ensure trash is picked up on a weekly basis. By November 15, 2013 Spring-Ford Counseling Services will contract with Garbage Disposal company this will ensure our capacity to manage trash overflow and closing of lids, Executive Director is responsible for this task. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and/or frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan in six of eight client records reviewed.
The findings include:
From September 11, 2013 to September 12, 2013, eight client records requiring documentation of the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plans were reviewed. The facility did not document the type and/or frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan in six of eight client records reviewed, specifically, client records # 2, 3, 5, 6, 7, and 8.
Client # 2 was admitted September 9, 2013. The individual treatment and rehabilitation plan was completed on September 9, 2013, but it did not include documentation of the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan as of September 12, 2013.
Client # 3 was admitted July 17, 2013. The individual treatment and rehabilitation plan was completed on July 24, 2013, but it did not include documentation of the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan as of September 12, 2013.
Client # 5 was admitted August 5, 2013. The individual treatment and rehabilitation plan was completed on July 29, 2013, but it did not include documentation of the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan as of September 12, 2013.
Client # 6 was admitted July 17, 2013 and discharged September 2, 2013. The individual treatment and rehabilitation plan was completed on July 24, 2013, but it did not include documentation of the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan as of September 12, 2013.
Client # 7 was admitted October 2, 2012 and discharged November 27, 2012. The individual treatment and rehabilitation plan was completed on October 9, 2012, but it did not include documentation of the frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan as of September 12, 2013.
Client # 8 was admitted December 12, 2012 and discharged April 17, 2013. The individual treatment and rehabilitation plan was completed on January 9, 2013, but it did not include documentation of the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan as of September 12, 2013.
The findings were confirmed during an interview with the project director on September 12, 2013 at approximately 12:00 P.M.
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Plan of Correction
On September 13, 2013, Executive Director notified all staff of treatment plan requirement to document type and/or frequency of treatment services and rehabilitation services. The opened treatment plans that did not have type/frequency of treatment services and rehabilitation services will by corrected by 11/1/2013,by therapist and reviewed by Executive Director upon completion of correction. Executive Director shall give an example to each therapist. Executive Director shall sign and review all treatment plans to ensure compliance on a bi-weekly basis. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan in four of eight client records reviewed.
The findings include:
From September 11, 2013 to September 12, 2013, eight client records requiring documentation of the proposed type of support services in the individual treatment and rehabilitation plans were reviewed. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in four of eight records reviewed, specifically, client records # 3, 4, 6, and 8.
Client # 3 was admitted July 17, 2013. The individual treatment and rehabilitation plan was completed on July 24, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of September 12, 2013.
Client # 4 was admitted August 12, 2013. The individual treatment and rehabilitation plan was completed on August 12, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of September 12, 2013.
Client # 6 was admitted July 17, 2013 and discharged September 2, 2013. The individual treatment and rehabilitation plan was completed on July 24, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of September 12, 2013.
Client # 8 was admitted December 12, 2012 and discharged April 17, 2013. The individual treatment and rehabilitation plan was completed on January 9, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of September 12, 2013.
The findings were confirmed during an interview with the project director on September 12, 2013 at approximately 12:00 P.M.
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Plan of Correction
On September 13, 2013, Executive Director notified all staff of treatment plan requirement of documenting proposed support services. Client records # 3, 4, 6, and 8 will be amended to include proposed type of support services by 11/1/2013, by therapist. Executive Director shall give each staff member an example of this requirement. Executive Director shall sign and review all treatment plans for compliance on a bi-weekly basis. |