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Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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RETREAT AT LANCASTER COUNTY PA, LLC
1170 SOUTH STATE STREET
EPHRATA, PA 17522

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Survey conducted on 01/30/2013

INITIAL COMMENTS
 
This report is a result of a complaint investigation conducted on January 30, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Retreat at Lancaster County PA were partially substantiated and 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

704.7(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.
Observations
Based on a review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of five records reviewed.



The findings included:



Twenty four personnel records were reviewed on January 30, 2013. Five personnel records were reviewed for meeting the requirements of counselor.



Employee # 24 was hired on August 15, 2011 as a counselor. The counselor did not meet the qualifications of counselor based on a Bachelor of Science degree in General Studies. Verification of the degree was documented in the record. A degree in General Studies is not an approved degree.



The findings were reviewed and confirmed with the facility director.
 
Plan of Correction
Employee will be changed from Counselor to Counselor Asst. HR will have employee sign new job description. This will be ensured and monitored by Exec Dir.

 
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