INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 3, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Lighthouse Counseling Associates 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
The facility failed to meet the pre-submission guidelines for the annual licensing inspection. The time allotted for the onsite portion of the inspection did not allow for a thorough review of that material on site.
This matter was reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the 7/23/2015 inspection.
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Plan of Correction
The C.E.O.of the facility will meet all pre-submission guidelines for the annual licensing inspection. All information needed will be submitted in enough time so information can be reviewed prior to licensing visit. The C.E.O. Will review and gather all information needed, obtain the forms needed, and send in to the Department of Program Licensingin the allotted time prior to site 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
The findings include:
The personnel record for Employee#1 who serves as the Project Director, Facility Director and counselor was reviewed for annual training hours on August 3, 2016.
The facility's training year is from July through June. The facility failed to document 12 clock hours of annual training for employee #1 for the July 1, 2015 - June, 2016 training year.
Employee # 1, a facility/project director, was hired in September of 1992. Employee record #1 contained no documentation of annual training hours for the July 1, 2015 - June 30, 2016 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All training hours will be completed on a yearly basis. This will be monitored and documented within the personnel file. This will be implemented immediately and carried out by the C.E.O. Of the facility. |
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
The findings include:
The personnel record for Employee#1 who serves as the Project Director, Facility Director and counselor was reviewed for annual training hours on August 3, 2016.
The facility's training year is from July through June. The facility failed to document 25 clock hours of annual training for employee #1 for the July 1, 2015 - June, 2016 training year.
Employee # 1, a facility/project director, was hired in September of 1992. Employee record #1 contained no documentation of annual training hours for the July 1, 2015 - June 30, 2016 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each staff member will complete 25 hours of continued training on a yearly basis. This will be monitored and documented with the personnel file. This will be implemented immediately and will be monitored throughout the year by the C.E.O. Of the facility. |