INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 6, 2007 - November 8, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alliance Medical Services 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 December 7, 2007.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on review of personnel records it was determined that there was insufficient documentation to demonstrate that employee # 2 had a human service or a business related degree that would qualify him for the position of facility director.
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Plan of Correction
The current Project Director for AMS has become the Facility Director for the facility. His qualifications meet state regulations for the position. |
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 personnel record reviews there was insufficient documentation to demonstrate that employee # 10 qualified for the position of counselor.
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Plan of Correction
The appropriate documentation was not in place at the time of licensing. The documentation supporting the qualifications of employee # 10 will become part of the personnell record. The Facility Director is responsible for completion of the plan of correction for the identified employee. In addition, it is the responsibility of the Facility Director to assure that all personnell records are in compliance with regulation and available for Department staff. |
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
Based on review of the "Staffing Requirements Facility Summary Report" completed by the facility employees # 12, 13 and 14 did not complete the mandatory training required for all staff. Employees # 12 and # 13 did not complete the six hours of Department of Health approved HIV/AIDS training and the four hours of TB/ STD and other communicable disease training. Employee # 14 did not complete the four hours of TB/ STD and other communicable disease training.
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Plan of Correction
Employees 12, 13, 14 did not complete the mandatory training in either HIV/AIDS or TB/STD.
The identified employees will attend the required trainings as soon as the specific trainings are offered locally. At a minimum, the identified staff will be trained within the next ninty days.
The Facility Director will be responsible for compliance in this matter. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of administrative records it was determined that there was insufficient documentation to demonstrate that employee # 10 qualified as a counselor. The caseload assigned to this employee is uncovered and exceeds the 35:1 caseload requirement.
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Plan of Correction
The 35:1 ratio was exceeded because there was insufficient documentation to demonstrate that employee #10 was qualified as a counselor. The documentation supporting the qualifications of employee # 10 will become part of the administrative record. The Facility Director will submit the appropriate documentation to the Department for review and approval. If approved, the ratio will be at the required 35:1 ratio. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on review of the client records it was determined that the facility failed to ensure that complete drug and alcohol histories were documented. The client's progression of use as it is related to the client's lengths and patterns of use was missing from 9 of 9 client records reviewed.
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Plan of Correction
Staff will be trained to include the progression of substance abuse relative to the lengths and patterns of use. The biopsychsocial history will also be amended to more clearly identify and explain these issues.
The Facility Director will be responsible for amending the form and for providing training in this area. The Facility Director and the Clinical Supervisor will be responsible for ongoing compliance. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on review of client records it was determined that the facility failed to ensure that personal histories were complete. Personal histories were consistently incomplete relative to family history, recreational history, employment history, educational history, legal history and sexual history in nine out of nine client records reviewed.
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Plan of Correction
Staff will be trained to document complete personal histories relative to family, employment, educational, legal and sexual histories. The biopsychsocial evaluation will also be amended to more clearly identify and explain these issues.
The Facility Director will be responsible for amending the form and for providing training in this area. The Facility Director and the Clinical Supervisor will be responsible for ongoing compliance. |