INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 21-22, 2019, by staff from the Division of Drug and Alcohol 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
The facility failed to ensure that all of its counselors had the required clinical experience prior to hiring them as counselors. Staff Person #7 was hired a Bachelor's Degree level counselor on April 23, 2019. Staff Person #7 was required to have at least one year of clinical experience before being hired as a counselor, but the staff person had no clinical experience at the time of hire. These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The counselor in question no longer works with the Agency. In the future this concern will be addressed during the interview process. Any individual that cannot provide documentation to meet the requirements of counselor would be hired as a counselor assistant and would be provided with close supervision. This would be done by shadowing an individual who does meet the requirements of counselor. The counselor assistant will meet weekly with clinical supervisor until they are able to take on a full caseload. This will be documented in employees file. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
During the administrative review of the project's staffing records and administrative documentation conducted at the facility on February 19, 2019, the group counseling session in the group room next to the conference room could be clearly heard from inside the conference room. These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
This problem has been rectified. Noise machines were purchased and have been placed in areas where counseling takes place. The group area had a noise machine placed there so conversation cannot be heard going forward. Sessions cannot be heard moving forward. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
During the administrative review of the project's staffing records and administrative documentation conducted at the facility on February 19, 2019, the hot water in the first floor clients' bathroom next to the facility director's office was tested at 140 degrees Fahrenheit. These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
This has been corrected as the hot water heater has been adjusted accordingly. The temperature is below the 120 degree maximum. In addition, temperature will be checked weekly by administration to ensure it is not over 120 degrees. Our HVAC company will service necessary components as well. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
On February 22, 2019, during the physical plant inspection, the fan in the second floor men's bathroom was not operable. These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The fan has been serviced. It is working at full function as of 3-18-19. This will be checked regularly by the maintenance department weekly. |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
On February 22, 2019, during the physical plant inspection, there were ceiling tiles in the first floor staff bathroom that were warped and had water stains. These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
This has been already corrected. Tiles have been replaced. It was water damage from the past. It was inspected and no further issues exist. All physical areas of agency will be checked by CEO on a weekly basis to ensure there are no issues moving forward. |
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
The client rights document that the facility has clients sign does not include notification that clients have the right to inspect their records. These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
This issue has been rectified as client rights and responsibilities have been changed to include the right to inspect their records . Clients are now aware of right to inspect their records upon intake/evaluation. Client signs the form as well. This form is in counseling offices as well. |
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
The client rights document that the facility has clients sign does not include notification that clients have the right to appeal the facility's decision to limit clients' access to their records. These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
This has been rectified by clinical supervisor. The document now includes notification that clients have the right to appeal the facility's decision to limit access to their records. This is also discussed and signed by client during intake process. |
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.
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Observations
The facility failed to ensure that it updated treatment plans at least once every 30 days in 1 of 3 applicable client records reviewed during the on-site inspection. A total of 5 partial hospital records were reviewed during the on-site inspection. Client #11 was admitted for partial hospital treatment on July 18, 2018, and was discharged from partial hospital treatment on August 29, 2018. The client's individualized treatment plan was dated July 18, 2018, but the treatment plan was never updated. These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
This has been addressed by the Clinical Supervisor moving forward. It is discussed at staff meetings and through email. In addition, this will be checked regularly by clinical supervisor during weekly chart audits. Training will occur at staff meetings as well in regards to treatment plans being updated every 30 days. Other case management topics will be discussed as well. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to clearly document the frequency of counseling on the individualized treatment plans in 3 of 4 applicable client records reviewed. A total of 7 outpatient records were reviewed during the on-site inspection. Client #1 was admitted for treatment on January 11, 2019. The client's individualized treatment plan was dated January 11, 2019. The treatment plan did document the frequency of counseling. Client #2 was admitted for treatment on August 6, 2018. The client's individualized treatment plan was dated August 27, 2018. The treatment plan reads, "The client will attend ongoing individual, outpatient counseling biweekly-monthly..." Client #3 was admitted for treatment on May 15, 2018. The client's individualized treatment plan was dated June 16, 2018. The treatment plan reads, "The client will attend ongoing individual, outpatient counseling biweekly-monthly..." These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Treatment plans have already been changed to reflect the frequency of counseling. This has been done by the Clinical Supervisor. In addition, the frequency will be written and discussed with client more specifically based on client needs. This will be monitored through weekly chart audits and also discussed in staff meetings. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to ensure that it updated treatment plans at least once every 60 days in 2 of 5 applicable client records reviewed during the on-site inspection. A total of 7 outpatient records were reviewed during the on-site inspection. Client #3 was admitted for outpatient treatment on May 15, 2018, and was an active client at the time of the on-site inspection. The most recent treatment plan update for the client was dated December 11, 2018, but another update was due February 11, 2019. Client #7 was admitted for outpatient treatment on February 1, 2018, and was discharged on November 17, 2018. The most recent treatment plan update for the client was dated August 16, 2018, but another update was due October 16, 2018. These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
This has been addressed by the Clinical Supervisor moving forward. It is discussed at staff meetings and through email. In addition, this will be checked regularly by the clinical supervisor during weekly chart audits. Training will occur at staff meetings as well in regards to treatment plan reviews being updated at least once every 60 days. Other case management topics will be discussed as well. |