INITIAL COMMENTS
|
This report is a result of an on-site inspection conducted for a capacity increase request. The inspection was conducted on April 1, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, James A. Casey House, LLC 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.
|
Plan of Correction
|
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.
|
Observations
Based on the review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of four records reviewed.
The findings include:
Four personnel records were reviewed on April 1, 2014. The facility failed to ensure that employee # 4 met the qualifications as a Master's level counselor. Record # 4 contained documentation of a Master's degree in Psychology but did not include documentation of a practicum in a health or human service agency.
The facility director confirmed the findings.
|
Plan of Correction
Counselor #4 will be a counselor assistant for at least the next 3 months under the close supervision of a trained counselor. Once they have satisfactorily completed the supervisory period they will become a full time counselor. The Clinical Director will be responsible for ensuring that all clinical staff meet the appropriate qualifications. |
709.26(d)(1) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(1) The application for employment.
|
Observations
Based on a review of personnel records, the facility failed to provide results of reference checks in two of three personnel records.
The findings included:
During the onsite inspection on April 1, 2014, three personnel records were reviewed. All personnel records require the documentation of reference results. The facility failed to document the results of reference checks in personnel records #3 and 4.
The facility director confirmed the findings.
|
Plan of Correction
Reference investigations have been completed for counselors #3 and 4 and the results have been placed in their employee records. The Project Director will be responsible for ensuring that all employee folders contain a reference check. The Project Director will review employee folders at least annually during personel evaluations to ensure that all records are complete. |