INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 3 - 4, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Abstinent Living at the Turning Point at Washington, 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 3, 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 two of two personnel records.The findings include:On August 3 - 4, 2009, five personnel records were reviewed. Two personnel records were required to have documentation of the qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel records # 2 and 3.Employee # 2 was hired as a counselor on December 1, 2008. Employee # 2 has a Bachelor of Arts in Public Service and a Masters in Business Administration. The Bachelor of Arts and Masters degree were reviewed by the Division and were found not to meet the educational requirements for the position of counselor.Employee # 3 was hired as a counselor on July 13, 2009. Employee # 3 has a Bachelor of Science in Social Work which meets the educational requirements; but does not have one year of required clinical experience. Employee # 3 has only eight months of clinical experience; which does not meet the minimum requirements for the position of counselor.
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Plan of Correction
Employee # 2 has applied for a her Certified Criminal Justice Addictions Professional Certificate as of 08/14/09 to the PCB Board. Her test date will be 09/11/2009. Before any hire for Counselor the Business Manager and Project Director will check Staffing Requirements Standards and document for the new hire's Personnel file.
Employee # 3 is recieving Direct Supervision for the next 4 months as a Counselor Assistant, by Project Director. Before any hire for Counselor, the Business Manager and Project Director will check Staffing requirements and document in the new hire's Personnel file. |
704.8(a) LICENSURE Qualifications-Counselor Assistant
704.8. Qualifications for the position of counselor assistant.
(a) A person who does not meet the educational and experiential qualifications for the position of counselor may be employed as a counselor assistant if the requirements of at least one of the following paragraphs are met. However, a project may not hire more than one counselor assistant for each employee who meets the requirements of clinical supervisor or counselor.
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Observations
Based on a review of personnel records and the facility staffing form, the facility failed to hire one employee who meets the requirements of clinical supervisor or counselor for each counselor assistant hired, as required.Five personnel records were reviewed on August 3 - 4, 2009. Five personnel records were for staff employed in clinical positions. For each counselor assistant the project hires; they are required to hire one employee who meets the requirements of clinical supervisor or counselor. Employees # 1 and 5 meet the qualifications of clinical supervisor or counselor. Employees # 2, 3 and 4 meet the qualifications of counselor assistant; which exceeds the number of counselor assistants permissible by 704.8(a).Employee # 1 is the facility director/clinical supervisor and meets the qualifications of clinical supervisor.Employee # 2 was hired on December 1, 2008 and meets the qualifications of counselor assistant. Employee # 2 was originally hired for the position of counselor, but did not meet the educational requirements.Employee # 3 was hired on July 13, 2009 and meets the qualifications of counselor assistant. Employee # 3 was originally hired for the position of counselor but does not meet the experiential qualifications.Employee # 4 was hired on December 20, 2007 as a counselor assistant and meets the qualifications for the position.Employee # 5 was hired in 2005 as a counselor and meets the qualifications for the position.
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Plan of Correction
Employee # 2 has applied for the Certified Criminal Justice Addictions Professional Certificate and will be directly supervised by employee #5 until she tentavely passes the test on September 11, 2009. Before any new hire for Counselor the Business Manager and Project Director will check Staffing Requirements and document in Personnel File.
The Project Director and Business manager will make sure that there are never again more Counselor Assistants than Counselors. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records and interview with the facility director and business manager, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of three personnel records.The findings include:Five personnel records were reviewed on August 3 - 4, 2009. Three personnel records were for the position of counselor. One personnel record required the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 5.Employee # 5 was hired in 2005 for the position of counselor. The facility training year is from July through June. Employee # 5 only completed 22 clock hours of annual training from July 1, 2008 through June 30, 2009. The facility director and business manager confirmed employee # 5 did not complete the required 25 clock hours of training.
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Plan of Correction
Employee # 5 received 23.5 clock hours annual training this was an oversight employee will receive 25 clock hours annual training in the future. The Business Manager will monitor this as she schedules most trainings for counselors. Training Certificates and feedback forms are given to the Business Manager who then copies them for her reference and puts original in personnel file. This will be overseen by the Project Director. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
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.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of personnel records and the facility staffing form, the facility failed to provide one FTE counselor for every eight clients, as required.The findings include:Five personnel records and the facility staffing form were reviewed on August 3 - 4, 2009. The facility provided one FTE counselor for every 10 clients; which exceeds the requirements of one FTE counselor for every eight clients. The clinical activity hours for counselors # 2 and 3 could not be included when determining the ratio; as these employees did not meet the qualifications for the position.
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Plan of Correction
A letter was sent to Licensure requesting 10-1 ratio and when Employee # 2 recieves her CCJP we will meet 8-1 ratio. The letter was sent by Business Manager and Project Director.
Before any new hire for Counselor Business Manager and Project Manager will check Staffing Requirements and document in personnel file. The facility will monitor how many clients are admitted to the program until Counselor Assistant receives Certification. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a review of the physical plant, the facility failed to provide slip-resistant surfaces in two bathtubs/showers.The findings include:On August 4, 2009 a physical plant inspection was conducted from 9:15 am to 10:30 am. The facility was required to provide slip-resistant surfaces in all bathtubs/showers. The facility failed to provide a slip resistant surface in the bathtub/shower on the third floor. The facility failed to provide a slip resistant surface in the claw foot bathtub on the main level. .
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Plan of Correction
Slip resistant surfaces have been placed in all bathtubs and showers. This was done on 08/04/09. Overseen by the Project Director. The Operations Manager will monitor to ensure they are in place Monday thru Friday. The Resident Monitors will check on weekends. This Policy has been added to The Resident Monitor Daily checklist. |
709.53(a)(12) LICENSURE Work as treatment
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to document that work done by the client at the project is an integral part of the treatment and rehabilitation plan in five of five client records.The findings include:Five client records were reviewed on August 3 - 4, 2009. Verification of work as an integral part of the treatment and rehabilitation plan was required in five client records. The facility did not document work as an integral part of the treatment and rehabilitation plan in client records #1, 2, 3, 4 and 5. The facility director confirmed that clients are assigned work at the project. The facility director reported the project was unaware this needed to be documented on the treatment plan.
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Plan of Correction
All therapist were instructed to include Life Skills on Treatment Plans on 08/06/09 at The Clinical Staff Meeting that meets every other Thursday by the Project Director. The Operations Manager who does the client filing weekly and the Business Manager who does chart reviews weekly will monitor this.
This will be overseen by the Project Director. |