INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 8 - 10, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cornell Abraxas 1 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 April 5, 2010.
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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 two of three personnel records.
The findings include:
On March 8, 2010, sixteen personnel records were reviewed. Three personnel records were required to have documentation of the qualifications for the position of counselor. The facility failed to ensure that each counselor met the qualifications of counselor in personnel records # 10 and 16.
Employee # 10 was hired as a Prevention/Education counselor on March 30, 2009. The full time position is for the non drug and alcohol population, but employee # 10 is utilized as a PRN counselor for the drug and alcohol unit. Employee # 10 has a Bachelor of Arts in Crime, Law and Justice which does not meet the educational qualifications of counselor position.
Employee # 16 was hired as a Prevention/Education counselor on April 19, 2009. The full time position is for the non drug and alcohol population, but employee # 16 is utilized as a PRN counselor for the drug and alcohol unit. Employee # 16 has a Bachelor of Science in Hospitality Management which does not meet the educational qualifications of counselor position.
A discussion with the Quality and Compliance Specialist on March 8 and 9, 2010 confirmed the two employees were utilized in the past year for the deliverance of drug and alcohol services, and they do not meet the minimum qualifications for the counselor position.
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Plan of Correction
The program manager and quality & compliance specialist met with the human resources coordinator and reviewed the qualifications of current education/prevention counselors. From that review, the human resources coordinator was able to develop a list of education/prevention counselors who met the required qualifications as outlined in the standards. If there is a need, these counselors will be used on a PRN basis to provide counseling to clients in the intensive drug and alcohol program. Each individual will sign a job description addendum. The addendum details the responsibilities and qualifications associated with the drug & alcohol counselor position.
As new education/prevention counselors are hired, the program manager and quality & compliance specialist will review their college transcripts and resumes. If the employee is qualified, the newly hired education/prevention counselor will be added to the list of PRN counselors. He/She will also sign the job description addendum.
The program manager and treatment supervisors will monitor the use of PRN counselors on a weekly basis to ensure only qualified counselors are used. The program manager will also be responsible for reviewing the PRN list on a monthly basis, ensuring its accuracy.
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