INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 2, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Spanish American Civic Association for Equality, Inc. was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility
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Plan of Correction
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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of employee charts on May 2, 2018, and an interview with the Facility Director, the Facility failed to ensure the counselor assistant met the requirements for counselor within 5 years of full time employment. The facility director had completed 3 two year petition to extend time to met the requirements.
These findings were confirmed with facility staff during the licensing process.
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Plan of Correction
Director met with employee and changed his position to House Manager until educational requirements have been met. This took place on May 3, 2018.
Employee has until August 2018 to meet requirements or position change will be permanent |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
A review of seven client records was conducted on May 4, 2018. Based on this review, the facility failed to complete A treatment plan update every 30 days for 3 out of 7 clients.
Client #3 was admitted on February 5, 2018 and was still an active client as of the date of this inspection. A treatment plan update was due to be completed on April 29, 2018 but was not documented as being completed during the inspection.
Client #5 was admitted on March 6, 2018 and was still an active client as of the date of this inspection. A treatment plan update was due to be completed on April 29, 2018 but was not documented as being completed during the inspection.
Client #6 was admitted on September 1, 2017 and was discharged November 24, 2017. A treatment plan update was due to be completed on October 22, 2017 and November 22, 2017 and was not documented as being completed during the inspection.
These findings were confirmed with facility staff during the licensing process.
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Plan of Correction
Director facilitated retraining on treatment plans on May 7, 2018. clinical supervisor will complete random weekly chart audits for 6 months, then monthly going forward. Director will complete random monthly audits ever month effective immediately |