INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Independent Family 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 counselors met the qualifications in two of two personnel records.
Six personnel records were reviewed on January 21, 2020. Two were reviewed as new counselors. Employees # 4 and 5 did not meet the qualifications for the position of a counselor.
Employee # 4 was hired as a counselor on Novemeber 6, 2018. At the time of hire, the employee had less than the required 1 year of experience.
Employee # 5 was hired as a counselor on May 22, 2018. At the time of hire, the employee had less than the required 1 year of experience.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The citation occurred because the staff did not met the 704.7 (b) qualification for the counselor position. Moving forward, the Project Director will assure all counselor requirements are obtained, as per 704.12 Licensure Counselor Qualifications. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to ensure that staff persons received the HIV/AIDS and STD/TB training as required in one of three personnel records.
Six personnel records were reviewed on January 21, 2020. Three required documentation of the mandated training.
Employee # 6 was hired as support staff on July 1, 2014. The mandatory training was to be completed by July 1, 2016. There was no documentation the training was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The citation occurred because the staff did not have the required 704.11 training. This staff attended the Mandatory Communicable Disease training which was held on February 14th, 2020. The remaining Mandatory Communicable Disease training hours will be scheduled once an available location is identified. Moving forward, the Project Director will ensure all employees who come in contact with clients in the drug and alcohol department obtain the necessary training as per 704.11 Staff Development Program requirements in the designated time frame. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
The facility failed to obtain a consent to release information in one of seven client records.
Seven client records were reviewed on January 21, 2020. All seven were reviewed for consent to release information. Client # 4 was missing a consent to release.
Client record # 4 documented three letters that sent to a government agency. There was no release of information documented for this agency.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This violation occurred due to the error of the staff failing to accurately complete the release. Moving forward, the Project Director will review with each counselor how to accurately complete a release of information document. The Project Director will review client charts for the following six months to ensure regulations as per 709.28 are met. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to obtain a consent to release information which included the specific information to be released in one of seven client records.
Seven client records were reviewed on January 21, 2020. All seven were reviewed for consent to release information. Client # 5 was missing a consent to release which included the specific information to be released.
Client record # 5 documented six letters that were sent to a government agency. The release of information documented for this agency did not include the information that was to be released.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This violation occurred due to the error of the staff failing to accurately complete the release. Moving forward, the Project Director will review with each counselor how to accurately complete a release of information document and verify that a release has been obtained before releasing information. The Project Director will review charts for the following six months to ensure regulations as per 709.28 are met. |