INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 20-21, 2018 by staff from the Division of Program Licensure. Based on the findings of the on-site inspection, RHD Lower Merion Counseling Services 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:
|
Plan of Correction
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of personnel records, the facility failed to document a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD training in two personnel records.
Employees #4 and 5 have been employed as counselors for more than one year, but there was no documentation that HIV/AIDS and TB/STD training had been completed.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Employee #4 was providing coverage for the caseload of LMCMS's previous D&A specialist who left in October 2017. This was to provide continuity of care to the effected clients. All DDAP-regulated clients have been moved off of her caseload except one, who has an appointment scheduled 04/10/2018. This client has been alerted to pending transfer, and it will be addressed at the appointment 04/10/2018. Employee #4 will no longer be providing D&A services.
Employee #5 attended TB/STD/Hepatitis 4 hour training on 03/15/2018. She is scheduled to attend the 6 hour HIV training 04/25/2018.
Facility has hired a D&A Coordinator and a D&A specialist to take over the D&A caseload. Having redundancy in staffing will allow for case-loads to be shifted appropriately in case of staffing changes. Additionally, several clinicians who do not currently see D&A clients have taken the required TB/STD and HIV/AIDS trainings, to avoid this in the future. When a staff member leaves, it is the responsibility of the Clinical Supervisor to redistribute their caseload or to hire someone to replace them.
|
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.
|
Observations
Based on a review personnel records, the facility failed to document a minimum of 25 hours of training in one personnel record.
The training record for counselor #3 documented 13 hours of training.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Employee #3 provided documentation of additional training hours completed in 2017 as a result of this audit. He is now at 34 training hours for the 2017 calendar year.
In the future, a newly implemented training tracking system will be kept by the QA Manager to make sure that each employee is on track to collect the necessary training hours under DDAP regulation. |