INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 20, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pathway to Recovery Counseling and Educational Services 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 five personnel records, the facility failed to ensure one counselor met the required clinical experience for the position.
Employee #4 was hired as a counselor on December 1, 2022. Employee #4 had a qualifying bachelor ' s degree and only nine months of clinical experience at the time of hire for that position.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective December 20,2022 Employee #4 was immediately removed from the position of D&A Treatment Specialist and placed back into the role of a Counselor Assistant. Employee #4 will remain a Counselor Assistant for an additional 3 months in order to meet the 12 months of clinical experience. The Clinical Director will assure through direct supervision that the Counselor Assistant has met qualifications prior to promotion. Upon hire, The Clinical Director will tally all Drug & Alcohol Counselors previous experience in order to ensure that they are hired in the correct position. The Clinical Director will place a timeline in the employee jacket with date of potential promotion to a Drug & Alcohol Counselor. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of five personnel records, the facility failed to ensure one counselor assistant was provided a written semiannual performance evaluation based upon measurable performance standard prior to being promoted to a counselor.
Employee #5 was hired as a counselor assistant on May 23, 2022 and promoted to a counselor on August 22, 2022. Employee #5 has a master ' s degree and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week."
Employee #5 did not have documentation of direct observation the week of June 13, 2022 - June 19, 2022. Employee #5 did not have documentation of a formal case review during the weeks of June 13, 2022- June 19, 2022, June 20, 2022- June 26, 2022, July 11, 2022- July 17, 2022, August 8, 2022 - August 14, 2022, August 15, 2022-August 22, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This citation was discussed with the members of the Quality Assurance Committee on December 20,2022. A decision was made that all future supervision for Counselor Assistants and D&A Treatment Specialists will be monitored by the Clinical Director to make certain that direct observation and close supervision is scheduled weekly. All documentation will be monitored on a monthly basis by the Clinical Director to make certain that each observation and supervision session is documented appropriately. The President and CEO will be responsible for implementing and monitoring this procedure. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one record reviewed.
Client #6 was admitted on September 1, 2022 and was current at the time of the inspection. Client #6 was a self-pay client until October 27, 2022. There was not a signed informed and voluntary consent from the client for the disclosure of information to a funder from October 27, 2022 on, however the facility admitted billing had been occurring.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During Treatment Team Meeting held on December 20,2022 the Clinical Director educated all counselors regarding the importance of completing a consent in its entirety. The counselors were each provided with examples of how a consent should be completed. The Clinical Director will conduct internal chart reviews throughout the year to ensure compliance is maintained. The agency will be in full compliance with this standard effective 12/20/22. |