INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 12-13, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Progressive Medical Specialists, 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 and a plan of correction is due on September 10, 2009.
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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 to ensure that each counselor met the qualifications for the position in one of two personnel records.
Findings:
Seven personnel records were reviewed on August 12-13, 2009. Two were reviewed as counselors. The facility did not ensure that the counselors met the educational requirements in personnel record # 6.
In personnel record #6, the counselor did not meet the qualifications for the position of counselor based on a Bachelor of Arts in Criminal Justice degree. In addition, a review of the Bachelor of Arts in Criminal Justice degree was reviewed by the Division on January 23, 2009 and was found not to meet the educational component for the position of counselor.
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Plan of Correction
Progressive Medical will continue to make every attempt to hire individuals with State approved degrees that will allow then to earn full counselor status as per regulations.
Advertisements, when hiring clinical staff, will be written with specific state approved degrees that will be needed to be held by potential employee.
If the best individual for the job holds a degree not approved by state, an individual training plan will be created within three days of employment, with the staff member and the clinical supervisor, which will include a plan for the staff member to obtain a CAC or/and other acceptable certification within a five year period.
Director will review each new clinical employee's education documentation, (degree and transcripts) with the clinical supervisor prior to hiring to ensure education meets state criertia for the staff member to earn full counselor status.
Documentation of this review will be found in the individual's personnel chart.
Staff member has signed a new job description on August 21, 2009 showing her as a counselor assistant.
Staff member and clinical supervisor, (on the same day) updated her individual training plan to include steps for staff member to achieve counselor status within the next four years as per state regulations. |
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 the review of personnel records, the facility failed to document satisfactory completion of one set of qualifications in 704.7 for a counselor assistant who was promoted to the position of counselor in one of one personnel record.
Findings:
Seven personnel records were reviewed on August 12-13, 2009. One personnel record was reviewed for the promotion of a counselor assistant to the position of a counselor. In personnel record # 6, there was no documentation provided that showed the counselor assistant had satisfactorily completed one of the sets of qualifications in 704.7 prior to her promotion to the position of counselor. The counselor assistant's degree was in Criminal Justice and did not meet the educational requirements of a counselor. Nor was there documentation that the employee had obtained a CAC (Certified Addiction Counselor) certificate.
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Plan of Correction
Any person interviewing for a clinical position will be asked to be a copy of the degree and transcripts to the interview.
Director will review each (potential) new clinical employee's education documentation, (degree and transcripts) with the clinical supervisor prior to hiring to ensure education meets state criertia for the staff member to earn full counselor status.
The clinical supervisor will monitor staff member's progress in obtaining full counselor status with monthly training updates/reviews.
When a counselor assistant is to believed to have met one of 704.7 standards regarding promotion to full counselor status the clinical supervisor will provide all documentation to director for review prior to promoting to full counselor status.
Documentation of this review and its finding will be found in the individual's personnel chart.
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709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on the review of the Client's Bill of Rights, the facility failed to demonstrate that the clients were informed of their rights in 15 of 15 client records.
Findings:
Eighteen client records were reviewed on August 10-11, 2009. Fifteen were required to have documentation demonstrating that the client was informed of their right to appeal a decision limiting access to his record to the project director in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 13, 14 and 17. There was no documentation on the client records that demonstrated the client was informed of their right to appeal a decision limiting access to his record to the project director.
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Plan of Correction
Director revised current policy and procedures to ensure that a statement in regards to the client's right to appeal a decision limiting access to his/her record on August 12, 2009.
Director, on August 12, 2009 updated the client handbook and the client right's information sheet completed at intake.
These updated forms and policy were reviewed with all staff members on August 14, 2009.
Updated information/ forms were used beginning August 17, 2009
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