INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the July 19, 2010 through July 22, 2010 licensure renewal inspection. The follow-up inspection was conducted on February 2, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Addiction Medicine and Health Advocate, 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 and a plan of correction is due on March 4, 2011.
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Plan of Correction
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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.
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Observations
Based on a review of personnel records, and a interview with the clinical supervisor, the facility failed to ensure that all staff obtained a minimum of 6 hours of training in HIV/AIDS and a least 4 hours related topics within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff.
The findings include:
Eight personnel records were reviewed on February 2, 2011. There was no documentation of HIV/AIDS and TB/STD training in one employee records. Client record #8 was required to have HIV/AIDS and TB/STD training within the first two years of employment.
Employee #8 was hired December 1, 2007 and was required to have HIV/AIDS & TB/STD training by December 1, 2009. There was no documentation of TB/STD as of to date. The clinical supervisor confirmed that employee #8 did not complete the required training.
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Plan of Correction
AMHA's Staff Development Coordinator will be responsible for monitoring, documenting and scheduling all required trainings within the required timeframes for all new employees. The Staff Development Coordinator will
schedule Employee #8 for the HIV/AIDS and TB/STD trainings immediately so her chart will be complete. The Staff Development Coordinator will ensure that she attends and that verification is placed in her employee chart. |
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 and an interview with the clinical supervisor, the facility failed to ensure and document that counselors completed at least 25 hours of training for the 2010 training year in one of three personnel records.
The findings include:
Eight personnel records were reviewed on February 2, 2011. Three employee records represented the counselors who were required to have obtained 25 hours of training for the 2010 training year based on the hire dates.
Employee #11 was hired 4/27/09 and was required to have obtained 25 training hours for the 2010 training year. Employee #11 only had 20.5 hours of training for training year 2010.
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Plan of Correction
The Staff Development Coordinator has created an Excel spreadsheet to document all scheduled and attended trainings for each staff person employed at AMHA. This will allow him to monitor each staff person's progress with meeting the required training hours which includes 25 hours annually for each counselor. The Staff Development Coordinator will ensure that the training hours are clearly documented on each training certificate so proper calculation can be done. This spreadsheet will be reviewed quarterly so he can schedule employees for training hours as needed to fulfill the requirements. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document all elements of a psychosocial evaluation in fifteen of sixteen client records.
The finding included:
Sixteen records were reviewed on February 2, 2011. Psychosocial evaluations were required in Sixteen records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,13,14, 15 and 16.
Client records #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16 failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselors conclusion and impressions.
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Plan of Correction
The Clinical Coordinator created a new biopsychosocial evaluation template form which was sent to the clinical staff. This is the template to be used for all biopsychosocial evaluations and contains all of the mandatory sections including. The Clinical Coordinator and Clinical Supervisor will be reviewing all completed paperwork for new patients, as is our procedure, to ensure that the proper form is being used and completed correctly. |