INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensing inspection that was conducted on August 6, 2015 by staff from the Program Licensure Division. Based on the supervisory review of findings from the on-site inspection, Project Transition 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 supervisory review:
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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 the supervisory review of the Staffing Requirements Facility Summary Report and a telephone conversation with the Project Director, the facility failed to ensure that each counselor met the qualifications for the position.
The findings include:
The Staffing Requirements Facility Summary Report (SRFSR), submitted and completed by the facility on July 6, 2015, was re-reviewed during the supervisory review on November 9, 2015. One employee was identified as not meeting the regulatory educational requirements, specifically a Bachelor's Degree in a related field in one of one employee.
Employee #1 was hired into the project on June 1, 2009 and was promoted to counselor status on August 14, 2013. According to the SRFSR, the employee received a Bachelor's Degree in 2003; however, the degree's major was in Sports Medicine, which does not meet the educational requirements for the position of counselor.
These findings were reviewed with the Project Director during a phone conversation on November 12, 2015.
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Plan of Correction
The Project Director has reviewed the findings of this and previous Facility Summary Reports and agrees that the identified employee does not meet the regulatory requirements for the counselor position. In previous site visits, we had clarified that in the role of Lead Psychiatric Counselor, this employee was dedicated to our licensed Community Residential Rehabilitation activities for the mental health residential apartments at this site. His responsibilities include supervision of our residential advisors, coordination of our medication room, and member case management. He was not listed as a counselor or assistant counselor.
For the 2015 site inspection, this employee was added to the counselor list by error. We have immediately rectified this error and he should not be listed as a counselor on our staffing report going forward.
We have immediately begun recruitment of a new full time staff person who will meet all qualifications to be listed as a counselor on our staffing report. This position is officially open effective 11/23/15.
Project Transition has reviewed and modified all job descriptions to reflect the staffing requirements for the counselor, assistant counselor and all other positions that fall under DDAP Staffing Requirements. This has been completed as of 11/30/15.
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