INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 6, 7, and 8, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital 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(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, the facility failed to document the completion of 12 clock hours of annual training required for facility directors in one of one personnel records.
The findings include:
Two personnel records were reviewed on August 7, 2013. Personnel record #1 pertained to the facility director. The facility failed to document 12 clock hours of annual training in personnel record # 1 as documentation provided in personnel record # 1 indicated indicated the employee received six hours or annual training.
The findings were confirmed by the facility director.
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Plan of Correction
The Director of Behavioral Health Services will meet with each Counselor to determine the number of hours completed thus far from their Training Plan and will assure they will complete their training hours by the end of the year. |
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 document the completion of 25 clock hours of annual training required for counselors in one of one personnel records.
The findings include:
Two personnel records were reviewed on August 7, 2013. Personnel record #2 pertained to a counselor. This employee was required to have 25 hours of annual training however there was only nine hours of annual training documented in personnel record #2.
The findings were confirmed by the facility director
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Plan of Correction
At a meeting on 9/3/13, a discussion was held between the CEO and the Director of Behaviroal Health Services to review the Director's annual training plan hours. Arrangements have been made for the Director to complete the required training hours by the end of the year. |
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 four monthly fire drills.
The findings include:
The fire drill record log was reviewed on August 8, 2013. The log was reviewed from August 2012 to July 2013. In a review of the fire drill information, the facilty did not document in four of twelve months that a fire drill was conducted; there were no fire drills recorded for July 2013, April 2013, January 2013, and October 2012.
The findings were confirmed by the facility director.
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Plan of Correction
The Director of Environmental Services is the responsible individual to conduct all fire drills at randomly scheduled times. This will be done once per month and while the outpatient program is in operation. The Fire Drill will be reviewed by the Director of Environmental Services to assured continued compliance on a monthly basis. |