INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 21-22, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, MinSec Treatment LLC 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
Based on a review of personnel records, the facility failed to ensure that each counselor met the educational qualifications for the position in one of three personnel records.
The findings include:
On November 21-22, 2013, six personnel records were reviewed. Three personnel records were required to have documentation of the educational qualifications for the position of counselor. The facility failed to provide documentation of a qualifying major in personnel record # 6.
Employee # 6 was hired as a counselor on August 13, 2013. Employee # 6 had a Bachelor of Science in General Studies. The facility failed to ensure that employee # 6 met the educational requirements for the position of counselor as the degree did not include a qualifying major.
The facility director confirmed the findings.
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Plan of Correction
Employee #6 will be immediately established and recognized as a counselor assistant effective 11-27-13, and in persuit of transfering current college transcript credits towards an MSW diploma at an accredited college/university and be registered by 2-28-14 or earliest date of enrollment. His projected date of completion of the MSW curriculum will be less than 2.5 years of this date of registration, but no later than 12/2016.
To ensure that all hired candidates meet the DDAP requirements to be considered "counselor" for positions applied for, candidates will need to provide original documentation of both diploma issued, transcripts in full to date, and will be reviewed by both clinical supervisor, facility director and finally the administrative assistant who will be assigned to the HR responsibilty/chart.This process will be in effect immediately, as of 12-3-2013. Additionally, prior to hiring the candidate, all three parties will need to agree that candidate is in compliance with 704 standards of operation and as evidneced by these original proofs and clinical expertise, work history and any other pre-exising qualifications. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's 2012 drug/alcohol abuse services.
The findings include:
The project's fiscal year runs from January 1st to December 31st.
The project's administrative records were reviewed on November 20, 2013. The project failed to obtain an independent financial audit of financial activities associated with the project's drug/alcohol abuse services for the 2012 fiscal year.
An interview with the facility director confirmed the findings.
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Plan of Correction
The facility director will work in conjunction with the project director through meetings and correspondence with corporate auditors to obtain independent financial audit associated with project's services for fiscal year 2012. |