INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on January 29, 2020. Based on the findings of the on-site inspection, Wyomingy Valley Alcohol and Drug Services was found to not 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
During a review of six staff records, the facility failed to ensure that each counselor with a bachelor ' s degree meet the qualifications.Staff #6 was hired on June 10, 2019 as a counselor. Staff #6 has a bachelor ' s degree in Spanish which is not a qualifying degree for a counselorThese findings were reviewed with the facility during the licensing process.
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Plan of Correction
Resumes are now reviewed by the CEO to ensure the proper degree is present. In addition, the CEO and Clinical Supervisor conduct interviews collaboratively to ensure all qualifications are met for the position of counselor. This particular counselor has been moved to counselor assistant where proper supervision takes place. In addition, the majority of her time is now spent doing intake/assessments. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
During review of policies and procedures on January 29, 2020, the project failed to notify clients of all their civil rights in seven out of seven records. Client #1 was admitted on January 16, 2016 and was current at the time of inspection. Client #1 was not notified that the project may not discriminate on the basis of sex, age, national origin and marital status. Client #2 was admitted on May 20, 2019 and was current at the time of the inspection. Client #2 was not notified that the project may not discriminate on the basis of sex, age, national origin and marital status. Client #3 was admitted on March 13, 2019 and was current at the time of the inspection. Client #3 was not notified that the project may not discriminate on the basis of sex, age, national origin and marital status. Client #4 was admitted on April 24, 2019 and was current at the time of inspection. . Client #4 was not notified that the project may not discriminate on the basis of sex, age, national origin and marital status. Client #5 was admitted on September 17, 2019 and was discharged on January 3, 2020. Client #5 was not notified that the project may not discriminate on the basis of sex, age, national origin and marital status. Client #6 was admitted on June 27, 2019 and was discharged on December 13, 2019. Client #6 was not notified that the project may not discriminate on the basis of sex, age, national origin and marital status. Client #7 was admitted on December 19, 2018 and was discharged on October 11, 2019. Client #7 was not notified that the project may not discriminate on the basis of sex, age, national origin and marital status. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The client rights in our records now reflects that the project may not discriminate on the basis of sex, age, national origin, and marital status. The client will sign the clients rights form, which now contains this. In addition, this is always explained during the intake process. This was also explained in staff meetings to employees which are held bi-weekly. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
During a review of policies and procedures on January 29, 2020, the project failed to notify seven out of seven clients that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. These findings were reviewed with the project during the licensing process.
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Plan of Correction
This has already been added in the clients rights portion of our intake. The form now reflects this policy. In addition, it is signed by the client and explained at intake with all clients. Also, this was discussed with employees at staff meeting. These staff meetings are held bi-weekly. Finally, CEO has added this policy into the Agency's manuals. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
During a review of policies and procedures on January 29, 2020, the project failed to notify seven out of seven clients that they have the right to appeal a decision limiting access to their records to the director. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
This was corrected and added into the clients rights portion of the document. This is explained to client during intake. In addition, it is signed off by client to ensure understanding. Also, it was explained to staff at staff meeting. These staff meetings are held bi-weekly. In addition, it is added to the agency's policies and procedures manual. |