INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8-9, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mainstream Counseling 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 upon the review of employee records, the facility failed to ensure that each counselor met the qualifications for the position in one of three counselors ' records reviewed.
The findings include:
Three employee records requiring documentation of the employees' educational and experience qualifications for the position of counselor were reviewed on April 8, 2014.
The facility failed to ensure employee #5 met the required experience for the position held.
Employee # 5 was hired as a counselor assistant on September 10, 2013 based on a BS in Human Development and Family Studies and promoted to a counselor on March 17, 2014.
The counselor does have a qualifying bachelor's degree, however lacks the required one year of clinical experience.
The findings were confirmed by the facility director and project director prior to the exit interview.
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Plan of Correction
Employee #5 was prematurely promoted from Counselor Assistant to Counselor on 3/17/2014. Following our Licensing Inspection on April 8-9, 2014, the Facility Director and Clinical Supervisor closely reviewed the Chapter 704 Staffing Requirements. The Facility Director met with Employee #5 on 4/10/14 to explain that her promotion was premature and she would be returned to Counselor Assistant status until her one year completion of clinical experience has been met. She is continuing to receive weekly clinical supervision. At the time of her one year employee evaluation in September, 2014 she will be promoted to Counselor if all staffing requirements have been sufficiently met. For all future promotions the Facility Director and Clinical Supervisor will first review and discuss the staffing requirements to avoid any further premature promotions. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of personnel records, the facility failed to document written job descriptions which contained the employee's and supervisor's dated signatures in three out of three personnel records reviewed.
The findings include:
Three personnel records were reviewed for current job descriptions on April 8, 2014. The facility failed to obtain the required documentation of a current signed job description in personnel records # 4, 5, and 6.
Employee # 4 was hired as a counselor assistant on February 7, 2012 and promoted to a counselor on June 1, 2013. There was no documentation of a signed job description for the position of counselor in personnel record # 4.
Employee # 5 was hired as a counselor assistant on September 10, 2013 and promoted to a counselor on March 17, 2014. There was no documentation of a signed job description for the position of counselor in personnel record # 5.
Employee # 6 was hired as a counselor on December 2, 2013. There was no documentation of a signed job description in personnel record # 6.
The findings were confirmed by the facility director prior to the exit interview.
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Plan of Correction
The Facility Director recognizes the lack of organization pertaining to the tracking of information in the employee personnel files. The Facility Director will develop a Personnel File Organizational System that will eliminate the oversight of updating required documentation relating to promotions, job descriptions, employee evaluations, etc. This organizational system will include a checklist to be reviewed quarterly to assure compliance with state regulations. The system will be created and implemented by the beginning of the next fiscal year, July 1, 2014. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of the client records, the facility released information that exceeded the limitations imposed at 4 Pa. Code subsection 255.5(a)(6).
The findings include:
Eight client records requiring consents to release information were reviewed on April 9, 2014. Two of eight client records reviewed included documentation of information released that exceeded the limitations imposed at 4 Pa. Code subsection 255.5(a)(6), specifically client records #3 and 5.
The findings include:
Client #3 was admitted to treatment on January 20, 2014. Client record #3 contained two letters, one dated 2/24/14 and the other dated 4/4/14 stating the client was in a drug and alcohol treatment program and providing the client ' s course in treatment; however the letter did not identify the recipient of the letter or the purpose for the release of information. Additionally, since there was no identified recipient or listed purpose included on the letter it was not possible to determine that a valid consent to release information had been completed.
Client #5 was admitted to treatment on November 13, 2014. Client record #5 contained a letter dated 4/4/14 addressed to the Bureau of Disability Determination stating the client was in a drug and alcohol treatment program and listing the client ' s prognosis.
There was no signed consent completed by the client to release this information.
The findings were confirmed with the clinical staff during the exit interview.
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Plan of Correction
An on-site review of Confidentiality Law is scheduled for Tuesday, June 3, 2014. At this time the Clinical Supervisor will review, in detail, 4PA Code 255.5. In addition, five of our clinical staff members completed the DDAP Training "Practical Applications for Confidentiality" on May 13, 2014; they will discuss this training with our additional personnel at our weekly staff meeting on May 20. A quarterly in-house review of Confidentiality Law will be implemented by the Clinical Supervisor and will be documented accordingly. Finally, a review of Confidentiality Law has been added to the new personnel checklist as a primary component of orientation. This will provide the fundamental basic understanding for new staff members until they are able to complete the DDAP required Confidentiality Training within their first year of employment. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project.
The findings include:
Three client records were reviewed for documentation of a termination letter on April 9, 2014. The facility failed to include notification to the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, specifically clients # 7, 8, and 9.
Client #7 was involuntarily terminated from the program on February 12, 2014. As of the date of inspection, there was no documentation of written notification to the client.
Client #8 was involuntarily terminated from the program on February 25, 2014. As of the date of inspection, there was no documentation of written notification to the client.
Client #9 was involuntarily terminated from the program on February 13, 2014. As of the date of inspection, there was no documentation of written notification to the client.
The findings were reviewed with clinical staff during the exit interview.
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Plan of Correction
For identified clients #7, 8, and 9, the chart deficiencies were addressed on April 9, 2014 following the departure of the DDAP Licensing Inspector. At that time counselors were instructed to follow through with sending of notification of termination letters which include the right to appeal. Please note that all clients are also informed of their rights to appeal any treatment decisions, including termination from treatment, at the time of admission as evidenced by their signed documentation of our Complaint and Appeals procedure. In addition, beginning June 3, 2014 and every first Tuesday of the month thereafter, the Clinical Supervisor will review each clinician ' s roster. At this time the Clinical Supervisor will identify cases that have been or need to be terminated, following up with the appropriate staff member to assure that the correct paperwork will be completed. The monthly roster review will enable the Clinical Supervisor to ensure that staff members are keeping their rosters updated and current to avoid lack of documentation or improper case closings. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility failed to document the clients ' medical, drug and alcohol, and/or personal histories as stated in facility policy in two of eight client records.
The findings include:
The policy referring to the biopsychosocial assessment, which includes the medical, drug and/or alcohol, and personal histories states: the comprehensive biopsychosocial assessment is to be completed within 30 days of admission.
Eight client records requiring documentation of histories were reviewed on April 9, 2014. The facility failed to document all or some of the client histories in client records # 7 and 8.
Client #7 was admitted to treatment on October 10, 2013 and discharged on February 12, 2014. As of the date of inspection, there was no documentation of a current drug and personal history for client #7.
Client #8 was admitted to treatment on July 25, 2013 and discharged on February 25, 2014. As of the date of inspection, there was no documentation of a current medical, drug and alcohol, or personal history for client # 8.
The findings were discussed with the clinical supervisor, facility director, and project director during the exit interview.
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Plan of Correction
The Clinical Supervisor will streamline the monitoring process of completion of the Biopsychosocial history taking for new clients; this will include the specific D&A history and personal history. Beginning in May, 2014 staff members will be instructed (at staff meetings) that they are to take any new client charts to clinical supervision.(Clinical supervision is scheduled a minimum of one time per month per staff member; counselor assistant's meet weekly). The Clinical Supervisor will review the intake and admission paperwork for signatures and thorough completion of required personal, medical, and D&A history. In addition, in June 2014 the Facility Director and Clinical Supervisor will assess the format of our Biopsychosocial History form, considering a change to the layout of the specific D&A history. If a change in format of gathering data is warranted, the Facility Director and Clinical Supervisor will work collaboratively to develop a more detailed format. This change will be reviewed and discussed with staff. Implementation of any changes will be documented in the staff meeting minutes as well as being documented by the Clinical Supervisor. This process will be completed by August 31, 2014. |