INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 23, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northern Tier Counseling, 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of five personnel records and a discussion with the facility director, it was determined that the facility failed to ensure that staff members completed a feedback form on all training attended.
The findings include:
In a review of five staffing records on August 23, 2011, confirmed that staff personnel records # 1 and 2 failed to complete feedback documentation upon completed training. The clinical supervisor and Facility Director confirmed that employee # 1 failed to complete the facility required feedback forms following the completion of training.
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Plan of Correction
NTC'S HR Manager currently keeps documentation on all trainings for all employees; NTCs plan of action will include HR Manager follow-up and review of the feedback forms for all trainings attended by all NTC staff throughout the year. Program Manager will also review quarterly all trainings attended by the D&A program staff, and ensure a feedback form is completed for all trainings attended; Program Manager will also report any trainings and feedback information to NTC's Compliance committee quarterly. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of personnel records and an interview with the clinical supervisor, the facility failed to document the completion of 30 clock hours of annual training required for the position of counselor assistant in personnel record #5.
The findings include:
Five personnel records were reviewed on August 23, 2011. The facility failed to document 30 clock hours of annual training in personnel record # 5.
Employee # 5 was hired on July 1, 2008. The facility training year is January through December. Employee # 5 completed 18 clock hours of the required 30 training hours.
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Plan of Correction
The Counselor Assistant will submit quarterly to the Program Manager a schedule of trainings attended and scheduled to ensure the 40 clock hour annual requirement is met annually.
****The Counselor Assistant DID complete 30 clock hours for the past year, a copy of the training hours was provided to the Licensing Specialist.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record log, the facility failed to document monthly fire drills.
The findings include:
The fire drill record log was reviewed on August 23, 2011. The log was reviewed from August 2010 through July 2011. Nine of those Eleven months failed to have documentation that a fire drill was conducted. January, February, March, April, June, and July, August, November, and December 2010 failed to have documented fire drills included in the fire drill log. This was confirmed by the director and clinical supervisor on August 23, 2011 at 1:30 pm.
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Plan of Correction
The Program Manager will ensure there is a fire drill scheduled and completed monthly, and documented in the log book. The HR Manager will also review the log monthly as well to ensure the drills are completed and documented, and the Compliance Committee will review the log bi-annually to ensure compliance. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, a review of the facilities policy manual, and an interview with the facility director, the facility failed to document a work performance evaluation according to policy in two of five records.
The findings include:
Five personnel records were reviewed on August 23, 2011 for documentation of a work performance evaluation.
The facility did not document a work performance evaluation in personnel records # 1 and 2.
Personnel # 1 date of hire was 12/01/2002. The last performance review was documented in 2009.
Personnel # 2 date of hire was 09/15/2008. The last performance evaluation was documented in 2009.
The facility director confirmed that the identified staff members have not had documented performance evaluations since 2009.
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Plan of Correction
The Facility Director's eval will be completed during NTC's quarterly Board Meeting in September, 2011, and annually moving forward. A compliance check will be reviewed by the HR Manager during NTC's next compliance meeting after the September Board meeting annually. The Facility Director will also complete an annual evaluation for the Clinical Supervisor in May, when all NTC employee annual evals are due. |