INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 2023 through July 12, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Marworth 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, the facility failed to ensure that all counselors met the appropriate educational and/or experiential qualifications for the position in one of eight applicable personnel records reviewed. Employee # 4 was hired as a counselor on April 20, 2023. The employee had a bachelor's degree; however, the degree was in an unqualifying major. Additionally, the employee did not have the required 1 year of clinical experience in a health of human service agency prior to hiring. The employee resume and personnel record only had documentation of 2 months of prior experience. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During Survey it was noted that a Counselor did not have a bachelor's degree that was qualified to allow him to be a Counselor under regulation 704.7(b) Licensure, Counselor Qualifications. It was also noted that he also did not have the required 1 year of clinical experience in a health of human service agency prior to his hiring as a counselor.
a. The Clinical Supervisor and the Clinical Director met with the individual and notified him that his title was being changed to Counselor Assistant on 07/12/2023.
b. Counselor Assistant will be provided with one hour of weekly supervision which will be documented in employee file.
c. Clinical Director will oversee clinical supervision being provided by clinical supervisor as evidenced by review of supervision notes and check-in during weekly supervisor meetings every Tuesday.
c. Counselor Assistant's training program will be revised to include updated supervision and successful completion of the training requirements in § 704.11.
d. The Counselor Assistant is also enrolled in a Master's Program with the anticipation of completing his Master's Degree in Clinical Counseling in May of 2024. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records and the policy and procedure manual, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services for clients in one of one applicable client records reviewed. The policy and procedure manual stated that the patient's emergency contact be notified as soon as the client indicates they wish to leave treatment against medical advice, providing the patient has not revoked consent to notify said emergency contact. Client #14 was admitted to the residential activity on March 19, 2023 and was discharged on March 30, 2023. Notification to the emergency contact was due no later than March 30, 2023; however, there was no documentation in the record that the facility contacted the emergency contact at the time of the client's discharge against medical advice. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director reviewed with the Counseling Department the policy and procedure of leaving against medical advice (AMA) in monthly staff meeting on 07/21/23.
a. Counselor will speak to emergency contact once notified that the client would like to leave AMA. Documentation will be provided in client chart under "contact note" indicating that emergency contact was notified or release was revoked.
b. Clinical Director will conduct montly audits on clients who left AMA beginning 08/01/23 and continue until there have been 3 consecutive months of 100% compliance of documenation of emergency contact being notified during AMA.
c. Clinical Director will report findings of each monthly audit at the PI meeting beginning 08/15/23.
d. Documentation of results will be placed in an electronic shared database (sharepoint) for counseling department to review.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans are reviewed and updated at least every 60 days in five of seven client records reviewed. Client #16 was admitted into the outpatient activity on January 12, 2023 and was active at the time of inspection. A treatment plan update was completed on February 17, 2023 and the next update was due no later than April 17, 2023. However, the update was not completed at the time of inspection. Client #17 wasadmitted into the outpatient activity on January 23, 2023 and was active at the time of inspection. A treatment plan update was completed on March 9, 2023 and the next update was due no later than May 9, 2023. However, the update was not completed at the time of inspection. Client #18 was admitted into the outpatient activity on January 16, 2023 and was discharged June20, 2023. The individual treatment plan was completed on January 23, 2023 and the first update was due no later than March 23, 2023. However, the update was not completed prior to the client's discharge. Client #19 was admitted into the outpatient activity on July 20, 2023 and was discharged February 28, 2023. The individual treatment plan was completed on August 3, 2022 and the first update was due no later than October 3, 2022. However, the update was not completed prior to the client's discharge. Client #20 was admitted into the outpatient activity on December 5, 2022 and was discharged March 16, 2023. The individual treatment plan was completed on December 21, 2022 and the fist update was due no later than February 21, 2023. However, the update was not completed prior to the client's discharge. This is a repeat citation from the June 2, 2022 annual licensure inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director reviewed with the Outpatient Counseling team the procedure of reviewing and updating all Treatment and Rehabilitation plans at least every 60 days on 07/14/23 during Master Treatment Plan (MTP) supervision.
a. Clinical Director to perform monthly PI audits beginning 8/1/23.
b. Clinical Director will review 15 active outpatient charts and 5 active intensive outpatient charts to ensure the policy on review of the Treatment and Rehabilitation plans are being documented at least every 60 days for a minimum of three months if 100% compliance is obtained.
c. The results will be compiled and distributed at monthly PI meeting beginning 08/15/23 with documentation of the audit.
d. Results will be communicated in the monthly PI meeting by Clinical Director verbally.
e. Results go to the Outpatient Counselors during MTP supervision on the last Friday of each month.
f. Documentation of results will be placed in an electronic shared database (sharepoint) for Outpatient Counselors to reference.
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