INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on May 29-31, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing 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 on the review of employee records, the facility failed to ensure that each employee identified as a counselor met the minimum educational and experiential requirements for one of one employee records reviewed.
The findings include:
During the licensure renewal inspection of May 29-31, 2012, nine employee records were reviewed. Seven of these records were those of clinical staff who were carrying individual caseloads. One of the employees identified as a counselor did not have the required one year of clinical experience for the position of counselor.
Employee # 7 was hired on 2/7/12 and had a single D&A client assigned to her as a caseload. The employee record failed to document the required one year of clinical experience for this individual.
The finding was reviewed with the Project Director and was not disputed.
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Plan of Correction
The job description for employee #7 has been changed from counselor to counselor assistant effective June 1, 2012. This individual does not work during the summer months. Therefore, the required supervision for counselor assistant, according to Staffing Requirements 704.9, will commence on September 4, 2012. Weekly clinical supervision will be scheduled and documented by our clinical supervisor, employee #6. In addition, weekly close supervision will be scheduled for a period of six months, from September, 2012 through February, 2013. At the end of the six month close and clinical supervision period a performance evaluation will be completed by the facility director, employee #3, and the clinical supervisor, employee #6. At this time, if employee #7 is satisfactorily rated she will be promoted to counselor. In order to avoid reoccurrence of this oversight in the future, facility director, employee #3, will assign all newly hired employees as counselor assistant until it has been clearly determined that they meet the specific requirements for counselor, as defined in chapter 704 of the Staffing Requirements. This will include a thorough review of any previous clinical experience reflected in supporting documentation from previous employers. Any change in employee status (from counselor assistant to counselor) will be discussed and mutually agreed upon by the facility director, employee #3, and the clinical supervisor, employee #6, and appropriately documented in the employee personnel file. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on the review of the facility policy and procedure manual and additional administrative materials presented, the facility failed to document notification to the public of the annual report within six months of the end of the reporting year.
The finding includes:
The licensing renewal inspection was conducted May 29-31, 2011. During the inspection all available administrative materials were reviewed. The annual report was complete. The public notification of the availability of the annual report must be made public within six months of the end of the reporting year. Mainstream Counseling has a fiscal year which runs from July 1- to June 30 annually. The annual report notification was not published until 1/3/12.
The finding was reviewed with the Project Director and was not disputed.
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Plan of Correction
Facility Director, employee #3, waited for completion of our annual audit before publicly posting the annual report, causing a delay in compliance with our stated policy. The facility director, employee #3, is now aware that the annual report may be posted without the annual audit because this report includes a summary balance sheet reflecting total assets and liabilities for Mainstream Counseling. For the fiscal year 2011-2012 the facility director, employee #3, will have the annual report prepared, completed, and posted for public notification by November 1, 2012. |
709.26(f)(3) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
(3) The requisite skills, knowledge and experience.
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Observations
Based on the review of the facility personnel records, the facility failed to document job descriptions which included the requisite skills, knowledge and experience for each employee .
The findings include:
The licensure renewal inspection occurred May 29-31, 2012. During the inspection, nine employee records were reviewed. Three of these records were for support staff. Three of three support staff records failed to document the requisite skills, knowledge and experience for the positions.
Record #7 - The employee started on 2/7/12. The job description for this employee failed to include documentation of the requisite skills, knowledge and experience for the position.
Record # 8 - The employee started on 9/26/11 . The job description for this employee failed to include documentation of the requisite skills, knowledge and experience for the position.
Record # 9 - The employee started on 11/4/11. The job description for this employee failed to include documentation of the requisite skills, knowledge and experience for the position.
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
Facility Director, employee #3, will revise the current job description for support staff to include the requisite skills, knowledge, and experience for the position. These revisions will be discussed and agreed upon with the project director, employee #2, by August 15, 2012. The revised job descriptions will be prepared by September 30, 2012 and will subsequently be signed by the appropriate employees (#7, #8, and #9) and placed in their personnel files. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on the review of client records and the facility policy and procedure manual, the facility failed to document physicals at the time of intake for each Medial Assistance funded client as required by facility policy.
The findings include:
The licensure renewal inspection occurred May 29-31, 2012. Eleven client records were reviewed during the inspection . Four of the records had identified funding resources as Medical Assistance (MA)/Healthchoices. Facility policy indicated that physical examinations were to be completed for clients who were funded by MA monies.
Client record # 3- This client was admitted on 4/18/12 and last treated on 5/15/12. The client was identified as being funded through MA monies. No physical examination was documented in the record.
Client record # 7- This client was admitted on 2/15/12 and last treated on 3/21/12. The client was identified as being funded through MA monies. No physical examination was documented in the record.
Client record # 8- This client was admitted on 8/1/11 and last treated on 3/12/12. The client was identified as being funded through MA monies. No physical examination was documented in the record.
Client record # 9- This client was admitted on 5/10/12 and last treated on 5/18/12. The client was identified as being funded through MA monies. No physical examination was documented in the record.
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
Project Director, employee #2, and facility director, employee #3, have discussed this citation and have agreed to revise the Outpatient Standards Manual to reflect that physical examinations are no longer required for MA clients. Therefore, the facility director, employee #3, will revise the stated policy (found in the Outpatient Standards - Intake Procedure 709.91(b)) by removing the following sentence:"At the initial session a referral for physical exam will be made if appropriate (i.e. MA funding, certain third party payers, etc.) unless referral has been made through the Central Assessment System." This revision will be completed by August 31, 2012. |