INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 17, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, MCP / Caring Together 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(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 facility failed to document that each counselor completed at least 25 hours of training annually.
The training hours for the July 1, 2017 - June 30, 2018 training year were reviewed on April 17, 2019. At the time of the inspection, staff #2, a counselor hired on November 17, 2015, had 7 hours of training documented for the 2017/2018 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager will monitor counselors' training hours to ensure that 25 hours are completed annually. Program Manger will address training hours during supervision and encourage counselor to register for trainings in a timely manner. Upon completion of trainings, certificates will be obtained from the counselor, copied and logged in the Training Manual. Program Manager will develop a spreadsheet to ensure that this plan is effective. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to notify clients, in writing, of the decision to involuntarily terminate the client's treatment at the project.
Client records were reviewed on April 17, 2019. One client reviewed was involuntarily terminated from the project. Client #7 was admitted to treatment on September 25, 2017 and involuntarily terminated on March 19, 2019. There was no written notification of involuntary termination in client record #7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager will re-train counselors regarding Discharge Procedures. Counselors will be trained to send letters of involuntary termination that notes the reason for separation and the right to appeal the termination decision.
Going forward, Program Manager will review discharge charts for the completed letter of termination. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
The facility failed to document policies and procedures to respond to the unusual incidents referenced in DDAP regulations. In addition, there was no policy in place stating that DDAP would be notified within 3 business days where required.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manger will develop policies and procedures to address the reporting of unusual incidents. The policy will provide guidance to document the unusual incident to clearly represent the occurrences that warranted the report, utilizing the appropriate DDAP document. Program Manager will provide training to the staff to clearly document unusual incidents and to include all pertinent information, including the names and contact numbers of all involved in the incident. The policies and procedures will include the names and contact numbers of those to be alerted regarding the incident
The policies and procedures will note that DDAP must be notified within 3 business days of the unusual incident. The unusual incident reporting form will be faxed to the number provided on the form. |