INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on April 8, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Clear Day Treatment of Westmoreland 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
The drug and alcohol treatment project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
Administrative documentation was reviewed. The project wide full-time counselors were 8.6 and required a full-time clinical supervisor. There were no clinical supervisors project wide.
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Plan of Correction
As of April 13, 2020 the Project Director will also serve as the Facility Director. On April 13, 2020 the past Facility Director reassigned by the Project Director to the position of Clinical Supervisor. He has signed a new job description which states he will supervise up to 8 full-time counselors. He meets the qualifications for the position of Clinical Supervisor. |
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
The facility failed to ensure that each counselor met the educational qualifications for the position.
Nine personnel records were reviewed. Six were reviewed for qualifications as new hires.
Personnel record # 7 did not document qualifying education. The employee had a master's degree, a bachelor's degree and a certification. The degrees were not qualifying degrees. The certification was an Associate Addiction Counselor, which is not a qualifying certification.
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Plan of Correction
On April 10, 2020 the employee (record # 7) that did not have the qualifying education for Counselor, was demoted to Counselor Assistant. The Employee was given 60 days to become fully certified as a CAADC in the state of Pennsylvania. Until the Employee obtains full certification in Pennsylvania she will receive close supervision by the Clinical Supervisor. The Clinical Supervisor will document the close supervision and report her progress to the Project Director. The Project Director is responsible for the oversight on her progress. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
The facility failed to conduct fire drills during sleeping hours at least every 6 months.
Fire drill logs were reviewed. The facility documented an overnight fire drill on June 16, 2019. The next overnight fire drill was documented on February 12, 2020. An overnight was to be conducted in December 2019.
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Plan of Correction
Beginning April 13, 2020 the Project Director or his designee will review and sign off on the fire drill log at least once a month. Additionally, on April 13, 2020 the Project Director has inserted the fire drill regulations in the forward section in the Fire Drill log. The Project Director met with the Tech Manager to discuss the importance of conducting 11pm.- 7am unannounced fire drills at least once every six months. The Project Director is responsible for ensuring this regulation moving forward. |