INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensing inspection that was conducted on October 19, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from the on-site inspection, Gaudenzia DRC, Inc., 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 supervisory review and a plan of correction is due on March 11, 2011.
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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 licensing packet on February 17, 2011, it was noted that the facility failed to ensure that all counselors met the educational and/or experiential requirements for the position.
The findings include:
Employee # 4, hired on June 28, 2010 had a Bachelor's of Psychology degree; however, the employee had less than one year of experience.
This had been confirmed by the facility Director during the October 19, 2010 inspection and the facility changed the position of employee #4 to that of a Counselor Assistant.
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Plan of Correction
DEFICIENCY ? 704.7 (b)
Counselor Qualifications
Plan of Correction:
Methodology:
Upon realizing that the counselor did not have the required experience, they were reclassified and put in the position as a counselor assistant. To ensure that the counselor assistant meets the educational and/or experiential requirements for the position, the Clinical Supervisor will closely supervise the counselor assistant for at least the first six (6) months of employment and document those supervision sessions.
The Clinical Supervisor will formulate a written training plan with the Counselor Assistant to specifically address their needs to achieve counseling competency per DOH Policy 704.11(f)(2) by June 28, 2011. Weekly supervisory sessions have been documented and clinical documentation of groups/individual sessions have been signed by the clinical supervisor.
The counselor assistant was given a written semiannual performance evaluation on December 28, 2010 based upon measureable performance standards. Continued performance standards will be monitored monthly during CQI meetings to ensure compliance, completion and timelines by the Inpatient Program Director.
The Facility Director will ensure that HR verifies that all new hires for the position of counselor meet the educational and experiential requirements for the position prior to hiring them for the position of counselor. The Facility Director will monitor this by reviewing all applications and supporting documentation for all potential candidates for the counselor position prior to HR making the job offer to the individual.
Timeframe for Completion: June 28, 2011
Persons Responsible:
Clinical Supervisor
Inpatient Director
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