INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7 through August 9, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on September 12, 2006.
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Plan of Correction
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709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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
Comprehensive treatment plans did not include the type and/or frequency of treatment being provided in three of five records reviewed, #1, 3 and 4.
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Plan of Correction
The treatment plan forms (Master & Updates) will be revised to include an area to indicate frequency of services-group and individual sessions. The New Insights policy will be revised to require a treatment plan update whenever there is a change in the client's frequency of services. These revised forms and policy revision will be presented to the Lemoyne staff at the scheduled staff meeting on October 4, 2006. This activity will be the responsibility of the Executive Director and will be completed on October 4, 2006. |
705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
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Observations
The facility did not have a smoke detector in the basement.
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Plan of Correction
A smoke detector will be installed in the basement area.
This action will be the responsibility of the Executive Director, and will take place by September 30, 2006. |
705.28 (b) (2) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(2) Place the smoke detector in a common area or hallway. All detection devices shall be interconnected.
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Observations
The smoke detectors were not interconnected.
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Plan of Correction
An electrical contractor will be hired to interconnect all the smoke detectors in the Lemoyne physical plant.
This task will be the prime responsibility of the Assistant Director, and is targeted for completion by October 15, 2006. |
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
Comprehensive treatment plans did not indicate the type of treatment being provided in two of eight records reviewed, # 6 and # 8, .
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Plan of Correction
The treatment plan forms (Master & Updates) will be revised to include an area to indicate frequency of services-group and individual sessions.
The New Insights policy will be revised to require a treatment plan update whenever there is a change in the client's frequency of services.
These revised forms and policy revision will be presented to the Lemoyne staff at the scheduled staff meeting on October 4, 2006.
This activity will be the responsibility of the Executive Director and will be completed on October 4, 2006. |
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
Employees # 5 and # 6 did not receive at least half of their training from persons not directly employed by the project.
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Plan of Correction
The monitoring of staff training hours will be converted to an automated system. Upon staff submitting evidence of trainings obtained, that information will be data entered on an ongoing basis. The training evidence, certification (and/or) training report form, will be inserted in the Annual Training Report binder. The policy will be revised that will require the Executive Director to review a monitoring report indicating the status of training hours on a quarterly basis. At these times, clinical staff members will be made aware of their total training hour requirement, and to assure that at least half of these training hours are obtained externally.
This task will be the joint responsibility of the Executive Director, Billing Supervisor, and Full-time Support Person (Lemoyne). The new automated system will be the task of the Billing Supervisor and will be in place by September 30, 2006. The Executive Director and Support Person will be responsible for maintaining and monitoring these reports of trainings. The Executive Director will revise the policy that will clearly describe this new method. |
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
Employee #1 did not receive 7 of the 12 required training hours for the 2004-2005 training year.
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Plan of Correction
The Executive Director will confirm that the total of (12) training hours are completed (or) scheduled for completion prior to the end of the training year (September 30, 2006). |
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
Three employees did not receive the required 25 training hours for the 2004-2005 training year; employee #4 received 4 hours, employee #5 received 20.5 hours and employee #6 received 17 hours.
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Plan of Correction
By utilizing the automated system that will be developed, as described in the response to standards 704.11 (C) (3) or (4), the Executive Director will monitor the status of required training hours for all clinical staff members on a quarterly basis. The Executive Director will notify the counselors who were delinquent and confirm that the total number of training hours are completed (or) scheduled for completion prior to the end of the current training year (September 30, 2006). |