INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 6 & 7, 2015 by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Wyoming Valley Alcohol and Drug Services, 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:
|
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 a review of thirteen personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of nine records reviewed.
Findings:
Nine personnel records requiring documentation of compliance with the qualifications for the position of a counselor were reviewed on January 6, 2015.
Employee #4 was hired on February 23, 2011 and promoted to the position of counselor on October 2, 2014. Employee #4's Bachelor of Arts in Women Studies degree does not meet the educational related field requirement. In addition, there was no documentation that Employee #4 had one year of clinical experience at the time of promotion.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Employee #4 is scheduled to take her CADC Certification test in the near future. She is also set to graduate with her MSW in May of this year. Given that she did not receive these as of now, she will be Supervised as a Counselors Assistant. Clinical Supervisor's will ensure she receives proper training for the next year. For the future, the Director who is in charge of hiring and promoting, will ensure potential clinicians meet both educational and experience requirements. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of staff training records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of nine personnel records reviewed.
The findings included:
Nine staff training records required documentation of the completion of 25 clock hours of annual training for counselors were reviewed on January 6, 2015. The training year for July 2013 to June 2014 was reviewed.
Employee #12 was hired on February 23, 2011. Employee #12 completed 3 hours of annual training for the 2013 / 2014 training year.
These finding were reviewed with facility staff during the licensing process.
|
Plan of Correction
Employee was let go from his duties due to agency financial issues with the understanding that he may not return to work at the Agency. He was employed by another institution that was not drug/alcohol related. However, he did leave that job and was made aware that a position had opened up within our agency once again. In the future, employees who are laid off will sign a document stating that it would be wise to still attain 25 hours of training annually. Also, Clinical Supervisors will ensure trainings are assessed before that employee is hired once again. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
|
Observations
Based on a review of client records, the facility failed to document a treatment plan update that included the impact of treatment, the possible revision of goals, the modification of strategies utilized to facilitate achievement of goals, and the documentation of gaols achieved in eight of ten records reviewed.
The findings include:
Ten client records that required documentation of treatment plan updates were reviewed on January 6, 2015.
Client #2 was admitted on January 1, 2014 and was discharged on September 5, 2014.
The treatment plan updates dated February 20, 2014 and March 20, 2014 did not have the impact of treatment, the revision of goals, the modification of strategies utilized to facilitate achievement of goals, and the acknowledgement of goals achieved documented.
Client #3 was admitted on February 19, 2014 and was discharged on July 19, 2014.
The treatment plan update dated April 18, 2014 did not have the impact of treatment, the revision of goals, the modification of strategies utilized to facilitate achievement of goals, and the acknowledgement of goals achieved documented.
Client #5 was admitted on April 21, 2014 and was discharged on June 27, 2014.
The treatment plan updates dated May 23, 2014 and June 23, 2014 did not have the impact of treatment, the revision of goals, the modification of strategies utilized to facilitate achievement of goals, and the acknowledgement of goals achieved documented.
Client #6 was admitted on July 30, 2014 and was discharged on September 25, 2014.
The treatment plan update dated September 4, 2014 did not have the impact of treatment, the revision of goals, the modification of strategies utilized to facilitate achievement of goals, and the acknowledgement of goals achieved documented.
Client #7 was admitted on January 15, 2014 and was discharged on September 5, 2014.
The treatment plan updates dated March 24, 2014, May 23, 2014 and July 23, 2014 did not have the impact of treatment, the revision of goals, the modification of strategies utilized to facilitate achievement of goals, and the acknowledgement of goals achieved documented.
Client #8 was admitted on October 20, 2014 and was still an active client on the date of the inspection. The treatment plan updates dated November 21, 2014 and December 19, 2014 did not have the impact of treatment, the revision of goals, the modification of strategies utilized to facilitate achievement of goals, and the acknowledgement of goals achieved documented.
Client #9 was admitted on November 15, 2014 and was still an active client on the date of the inspection. The treatment plan update dated December 11, 2014 did not have the impact of treatment, the revision of goals, the modification of strategies utilized to facilitate achievement of goals, and the acknowledgement of goals achieved documented.
Client #10 was admitted on November 26, 2014 and was still an active client on the date of the inspection. The treatment plan update dated December 31, 2014 did not have the impact of treatment, the revision of goals, the modification of strategies utilized to facilitate achievement of goals, and the acknowledgement of goals achieved documented.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Treatment Plan updates will be reviewed with Clinical Supervisors at least once every 30 days to ensure that the correct information is assessed and implemented. This will include impact of treatment, revision of goals etc. Also, this will be discussed at each staff meeting by the Clinical Supervisors. This allows for consistent Treatment Plan updates. |