INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 11-12, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Coatesville Treatment Center 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 the agency self reporting staffing form, the employee records and interviews with administrative staff, the facility failed to ensure the employee met the minimum experience for two of thirteen counselors.The findings included : Two counselors were hired within the past six months. The counselors had both earned bachelor degrees in related majors. However, based on the review of the resumes submitted by employee # 1 and employee # 2, they did not have the required one year of clinical experience.
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Plan of Correction
As of 3/19/2014, Clinic Director will review all resumes with Clinical Supervisors prior to any scheduled interviews to determine if the candidate meets the requirement for a Counselor Assistant or Counselor. Any questionable resumes will be asked for additional clarification to be highlighted within the body of their resume. If they do not meet the requirements for a Counselor, they will be hired as a Counselor Assistant pending they meet the requirements as highlighted in the staffing regulations listed in the Policy and Procedure Manual. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of administrative documentation, the facilty failed to ensure alternate exits were used during fire drills. The findings include:Administrative documentation that included the monthly fire drills for the prior twelve months, was reviewed February 10, 2014. The exit used was not documented to verify the exits were alternated. This is a repeat deficiency from the inspection dated May 6, 2013.
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Plan of Correction
On 2/13/2014, the New Health & Safety Officer was trained and informed that all exits used during the fire drills had to be noted on the monthly documentation. Clinic Director will review the fire drills each month to ensure the exits are noted on the documentation. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to ensure an individual treatment plan was completed as required in six of seven client records reviewed. The findings include:Twenty two client records were reviewed February 10-12, 2014. Seven client records were reviewed for an individual treatment plan. Client # 4 was admitted December 19, 2013 and did not have an individual treatment plan in the client record at the time of the inspection.Client # 7 was admitted December 6, 2013 and did not have an individual treatment plan in the client record at the time of the inspection.Client # 8 was admitted December 17, 2013 and did not have an individual treatment plan in the client record at the time of the inspection.Client # 11 was admitted October 15, 2013 and did not have an individual treatment plan in the client record at the time of the inspection.Client # 21 was admitted May 8, 2013 and did not have an individual treatment plan in the client record at the time of the inspection.Client # 22 was admitted May 30, 2013 and did not have an individual treatment plan in the client record until August 23, 2013.
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Plan of Correction
On 3/24/2014, Clinical Supervisors will conduct a training on treatment planning, which will include a review of due dates, measurable goals and objectives, clinical language, indication of progress, and individualized treatment. Counselors will be required to bring a sample treatment that will be reviewed and discussed during the training. Clinical Supervisors will continue to conduct random monthly chart audits and facilitate quarterly peer reviews to ensure timeliness of clinical documentation. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records and discussion with administrative staff, the facility failed to ensure both short and long term goals were formulated with the client in three of three client records reviewed.The findings include:Twenty two client records were reviewed February 10-12, 2014. Three client records contained an individual treatment plan. Three client records, # 3, 5 and 22 did not have long term goals formulated at the time of the inspection.
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Plan of Correction
On 3/24/2014, Clinical Supervisors will conduct a training on treatment planning, which will include a review of due dates, measurable goals and objectives, clinical language, indication of progress, and individualized treatment. Counselors will be required to bring a sample treatment that will be reviewed and discussed during the training. Clinical Supervisors will continued to conduct random monthly chart audits and facilitate quarterly peer reviews to ensure timeliness of clinical documentation. |