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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 10/12/2021

INITIAL COMMENTS
 
This report is a result of an on-site licensure renewal inspection conducted on October 12, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Retreat at Lancaster County PA, 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:
 
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 eleven personnel records on October 12, 2021, it was determined that one employee did not meet the experience requirements to be a counselor. Employee #8 was hired as a counselor on May 13, 2021 and was current at the time of the inspection. At the time of hire, employee #8 had a bachelor ' s degree but did not have the required one year of clinical experience.These findings were reviewed with facility staff during the licensing process.
 
Plan of Correction
To correct this deficiency, the referenced employee has been removed from her position as a counselor and has been placed in a clinical support role, until she meets the requirement of one (1) year of clinical experience. Employee will be placed back in a counselor role upon completion of an entire year of clinical experience.

To ensure ongoing compliance, the Executive Director will now review all applications/resumes for all clinical/counselor positions to verify that the selected candidate has the appropriate qualifications and experience. Applicants will not be hired for these roles unless the Executive Director has approved the hire.

 
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