INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from April 29, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Case De Consejeria Drug and Alcohol Counseling Program 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(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form and a review of personnel records, the facility failed to ensure at least one-half of all training was provided by trainers not directly employed by the project. The findings include:The Staffing Requirements Facility Summary Report form was completed by the facility on March 20, 2015. The facility failed to ensure at least one-half of all training was provided by trainers not directly employed by the project.The staffing form revealed that more than half of the 2014 training was provided in-house. In addition, two personnel records were reviewed and contained documentation of only facility training certificates. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Casa de Consejeria's Facility Director along with the clinical supervisor will ensure that all clinical staff will obtain at least half of their indicated trainings from an outside provider or consultant. These trainings will be in accordance to the employee assessment and the individual training plan, which is already developed. The facility director will implement staff development, training topics, trainings availability and training hours as a regular agenda item while conducting monthly supervision meetings with the clinical supervisor and also in the biweekly meetings with administrative staff. The combination of these two meetings will result in not only making sure that we are sending clinical staff to appropriate trainings but also that they are scheduled regularly in order to meet this requirement by December 31, 2015. |
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 each counselor completed at least 25 clock hours of annual training.The findings include:Two employee records were reviewed on April 29, 2015, for documentation of the 2014 annual training requirements. The facility failed to ensure that each counselor completed at least 25 clock hours of annual training, specifically employee # 4. Employee #4 was hired on July 10, 2012 as a counselor and was required to obtain 25 training hours for the 2014 facility training year. Employee #4 obtained 24 hours of training for training year 2014. Additionally, the facility documented on the Staffing Requirements Facility Summary Report, completed by the facility on March 20, 2015, that employee #4 received 24 hours of training.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director along with her administrative assistant will conduct monthly personnel reviews to ensure that all employees are completing their determined training hours on a timely basis. This will also be connected to the biweekly administrative staff meetings where regular follow up will take place for this task. A new personnel file checklist will be developed by the Facility Director to further ensure that all staff training requirements and responsibilities are met. The checklist, the implementation of the monthly reviews, and the addition of this meeting topic will be in effect no later than June 30, 2015. |