INITIAL COMMENTS
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This report is a result of an on-site licensure initial inspection conducted on November 22, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, STR Addiction Counseling, LLC 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records and the facility's Staffing Requirements Facility Summary Report (SRFSR) form completed on November 22, 2013, the facility failed to ensure that each counselor met the qualifications for the position of counselor in one of one personnel record reviewed.
The findings include:
On November 22, 2013, one personnel record and the facility's SRFSR form were reviewed for documentation of the qualifications for the position of counselor. The facility failed to ensure that each counselor met the appropriate clinical experience requirement for the position of counselor in one of one personnel record reviewed, specifically, personnel record # 1.
Employee # 1, the project director and counselor, was hired January 15, 2013. A review of the personnel record for employee # 1 indicated that the documentation for work experience requirements for the position was insufficient. The documentation indicated that employee # 1 had a Bachelor of Arts in Psychology but did not have any clinical experience.
The findings were confirmed during a supervisory review with the Drug and Alcohol Licensing Specialist Supervisor and the findings were presented to the project director.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on observations on November 22, 2013, the facility failed to light interior exits at all times.
The findings include:
A physical plant inspection was conducted on November 22, 2013. Areas of the side interior emergency exit of the facility leading towards the rear parking lot were not lighted during the physical plant inspection. This condition was observed at approximately 11:25 A.M.
The findings were confirmed during an interview with the project director at approximately 11:26 A.M.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based on observations on November 22, 2013, the facility failed to have a fee schedule posted.
The findings include:
A physical plant inspection was conducted on November 22, 2013. It was observed during the inspection at approximately 11:00 A.M. that the facility did not have a fee schedule posted.
The findings were confirmed during an interview with the project director on November 22, 2013 at approximately 11:02 A.M.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |