INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 16, 2020 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, New Insights II, 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:
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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 training documentation, the facility failed to document that each staff person received a minimum of 6 hours HIV/AIDS and 4 hours of TB/STD training.Staff #4 was hired as a counselor on July 1, 2019. HIV/AIDS and TB/STD training was due to be completed by July 1, 2020. There was no HIV/AIDS or TB/STD training documented for Staff #4.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of November 23, 2020, the Executive Assistant will take over ensuring that all clinical staff have a minimum of 6 hours of HIV/AIDs training and 4 hours of Tuberculosis, STDs, and other health related topics completed within one year of hire. As the Executive Assistant is going to begin tracking clinical staff's required training hours each year, they will also be responsible for communicating to clinical staff the required trainings, what date they need completed by, and provide resources for the clinical staff to set up the trainings. A reminder memo will be sent out to all clinical staff every quarter that will include a list of the required courses and the date they completed them. The Project Director will also be sent a copy of all clinical staff's reminder memos on a quarterly basis to help ensure compliance.
Staff #4 received 6 hours of DDAP approved HIV/AIDs training through remote learning on November 18, 2020, and 4 hours of DDAP approved Tuberculosis and other STD modules through remote learning on November 18, 2020. |
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 and training records, the facility failed to document that each counselor completed at least 25 hours of training for the 2019 training year.Staff #3 was hired as a counselor on April 10, 2017. Staff #3 completed 12 hours of training for the 2019 training year, which runs from January - December.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of November 23, 2020, the Executive Assistant will start tracking clinical training hours to ensure all applicable clinical staff receive 25 hours of relevant training during the training year. Our training year runs from January-December and the Executive Assistant will send out quarterly reminder memos with each clinical staff's current trainings and training hours documented to the clinicians. The clinical team will be responsible for ensuring the Executive Assistant receives a copy of all of their training certificates. The Project Director will also receive a copy of each clinical staff's memo to ensure compliance by the clinical team. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of administrative documents, the facility failed to document an annual report and make it public.The licensing specialist requested the 2019 annual report. Per the executive assistant, there was no annual report documented for 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of November 23, 2020, the President of the company will take over responsibility for the annual report being completed. In December of 2019, the bookkeeper had the responsibility to complete the annual report and was asked to by management. It was discovered it had not been done in January 2020 when the bookkeeper quit abruptly. The President will now be responsible for the completion of the annual report and distributing it to the necessary people and to the Executive Assistant so they can make it available to the public. An annual report will be done in December 2020 and made available to the public and distributed to the necessary people. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documentation, the facility failed to document an annual financial audit of activities associated with the project's drug/alcohol abuse services.The facility has an exception to the annual financial audit requirement; however, this exception is only valid if the project maintains the criteria required for the exception. For the 2019 fiscal year, tax information was provided and the project no longer met criteria for the exception, making the exception no longer valid. An annual financial audit was required to be completed for 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of November 23, 2020, the President will be responsible for hiring an independent accountant/firm to document an annual financial audit of activities associated with the project's drug/alcohol abuse services. It will be the President's responsibility to research and recruit a reputable independent accountant/firm to document a financial audit and we will have documentation of a financial audit done for 2019 and 2020 and annually thereafter. Due to several factors, including the current pandemic and loss of revenue as a result, the President will be writing to ask for an exception. However, if an exception is not granted, the President will recruit a reputable independent accountant/firm and the 2019 and 2020 audits will be completed by April 1, 2021. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document an annual written performance evaluation that was reviewed and signed by the employee in staff record #1.The staff #1, the project/facility director, was hired on February 6, 2017. There was no written annual performance evaluation documented for 2018 or 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The President of the company will be responsible for documenting an annual performance review for staff #1, the Project Director. Staff #1 was hired in February of 2017 and will begin getting an annual performance review in December of 2020. The President will continue to document an annual performance review for Staff #1 in December of each year. |