INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 15, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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:
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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, the facility failed ensure that all counselors met the appropriate educational and/or experiential qualifications for the position in two of two applicable personnel records reviewed.
Employee # 8 was hired as a counselor on November 14, 2022. The employee had a bachelor ' s degree with a qualifying major; however, the employee did not have the required 1 year of clinical experience in a health or human service agency prior to hiring.
Employee #12 was hired as a counselor on January 30, 2020. The employee had a bachelor's degree; however, the major was in Spanish, which is a non-qualifying major.
This is a repeat citation from the February 16, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Hiring continues to be extremely difficult. We have met as an Administrative team to help rectify this issue. All members of administration will be in on resume review and interviews. This includes the CEO, Clinical Supervisors and Lead Counselor. No one will be hired as a counselor unless they meet both the educational and experience requirements. Otherwise, they will remain a counselor assistant until the proper supervision and promotion to counselor is possible based on evaluation. The employees listed will remain assistants until supervision is complete and we feel they are thoroughly evaluated to be counselors (ones with qualifying degrees). This will be monitored by the Clinical Supervisor and Lead. It is in process. Their roles have been changed back to counselor assistants on 2-16-23. As far as #12, she is eligible for her CADC and will be taking the test in the near future which will qualify her if she passes. |
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 personnel records, the facility failed to ensure that all counselor assistants, with a bachelor's degree, were counseling clients only under the close supervision of a trained counselor or clinical supervisor for at least the first six months of employment in four of four applicable personnel records reviewed.
Close supervision is defined as formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week.
Employee # 5 was hired as a bachelor's-level counselor assistant on May 31, 2022. The employee supervision notes did not document a formal case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week.
Employee # 6 was hired as a bachelor's-level counselor assistant on March 28, 2022. The employee supervision notes did not document a formal case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week.
Employee # 7 was hired as a bachelor's-level counselor assistant on June 6, 2022. The employee supervision notes did not document a formal case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week.
Employee # 9 was hired as a bachelor's-level counselor assistant on March 28, 2022. The employee supervision notes did not document a formal case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have met as an supervisory team to discuss this issue. Even though 6 months of supervision was completed, we do realize that we were missing elements such as formal case review and an additional hour of direct observation documented per week. This will be done with the lead or clinical supervisor and assistant weekly and documented in employee files. In order to avoid happening again, as mentioned above, this will include chart reviews, consultations etc. We have begun the process to correct it. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that a counselor assistant satisfactorily completed the required educational and experiential qualifications prior to being promoted to the position of counselor in three of four applicable personnel records reviewed.
Employee # 6 was hired as a bachelor's-level counselor assistant on March 28, 2022 and was promoted to a counselor on September 29, 2022. At the time of the promotion, the employee only had six months of documented clinical experience in a health or human service agency; however, one year of clinical experience is required to qualify as a counselor.
Employee # 7 was hired as a bachelor's- level counselor assistant on June 6, 2022 and was promoted to a counselor on December 7, 2022. At the time of the promotion, the employee only had six months of documented clinical experience in a health or human service agency; however, one year of clinical experience is required to qualify as a counselor.
Employee # 9 was hired as a bachelor's-level counselor assistant on March 28, 2022 and was promoted to a counselor on September 29, 2022. At the time of the promotion, the employee only had six months of documented clinical experience in a health or human service agency; however, one year of clinical experience is required to qualify as a counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This will be corrected by the supervisory team by keeping those employees without both requirements as Counselor Assistants for at least one year. This includes weekly supervision with all the elements required as per meeting and documentation. After 1 year, they will be evaluated and promotion will occur if all requirements have been satisfied. As far as employee #7, they will need to continue as an assistant until experience is met, supervisory time is positive, and evaluation allows for promotion to counselor. This will conducted by the Clinical Supervisor and lead counselor to ensure supervision and experience is met to be a Counselor. Employee #7's role was changed from counselor back to assistant on 2-16-23. |