INITIAL COMMENTS
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This report is a result of an on-site licensure initial inspection conducted on September 24, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Children's Service Center of Wyoming Valley, 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 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 personnel records and the Staffing Requirements Facility Summary Report (SRFSR) form, the facility failed to ensure that each counselor met the educational qualifications for the position of counselor.The findings include:On September 24, 2012, the SRFSR form and three personnel records were reviewed for documentation of the educational qualifications for the position of counselor. The facility failed to ensure that each counselor met the appropriate educational qualfications for the position in one of three personnel records reviewed, specifically, personnel record # 5.Based on the SRFSR form completed by the facility on November 21, 2011 and employee # 5's resume, employee # 5 was documented as having a Bachelor of Science in Psychology. A review of employee # 5's degree indicated that employee # 5 has a Bachelor of Science. However, the degree did not indicate the major of the degree. On September 24, 2012, the Licensing Specialist asked to see a copy of employee # 5's transcript verifying that he has a Bachelor of Science in Psychology. A copy of the employee # 5's transcript verifying that he has a Bachelor of Science in Psychology was not presented for review.The findings were confirmed during an interview with the human resources representative on September 24, 2012 at approximately 2:00 P.M.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records, the facility failed to provide documentation for the results of reference investigations. The findings include:On September 24, 2012, eight personal records requiring documentation of reference checks and seven personnel records requiring documentation of a FBI fingerprint background check in accordance with the Child Protective Services Law Act 73 were reviewed. The facility did not provide documentation of reference checks in two of eight records reviewed, specifically, personnel records # 1 and 3. Also, the facility did not provide documentation of a FBI fingerprint background check in one of seven records reviewed, specifically, personnel record # 7.Employee # 1 is the project director and was hired on December 16, 2008. Employee # 1 was due to have reference checks upon employment at the facility. However, personnel record # 1 did not include documentation of reference checks as of September 24, 2012.Employee # 3, a counselor, was hired for his initial position on June 14, 2004 and hired for his current position on December 1, 2008. Employee # 3 was due to have reference checks upon employment at the facility. However, personnel record # 3 did not include documentation of reference checks as of September 24, 2012. Employee # 7 is the administrative assistant and was hired on November 7, 2011. Employee # 7 was due to have a FBI fingerprint background check upon employment at the facility. However, personnel record # 7 did not include documentation of a FBI fingerprint background check as of September 24, 2012. The findings were confirmed during an interview with the human resources representative on September 24, 2012 at approximately 2:00 P.M.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |