INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 4 - 7, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cornell Abraxas I 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 eighteen personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of nine records.
Findings:
Eighteen personnel records were reviewed on March 4-5, 2013. Nine of the eighteen personnel records reviewed were for the position of counselor. One of the nine counselors reviewed did not meet the educational qualifications for the position of counselor.
In personnel record #2, the staff member transferred into the drug and alcohol activity as a counselor assistant on December 9, 2012 and was promoted to the position of counselor on February 17, 2013. The counselor has a Bachelor of Science degree in an unrelated field, and does not meet the educational qualifications for the position of counselor.
The finding was reviewed with the Quality and Compliance Specialist and was not disputed.
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Plan of Correction
The Facility Director, Assistant Facility Director, Clinical Supervisor, Program Managers, Quality & Compliance Specialist and Human Resources Coordinator met on March 26, 2013 regarding employee #2 who was promoted to a Counselor without the required educational qualifications. Employee #2 was reclassified as a Counselor Assistant on March 31, 2013.
Employee #2 will receive direct supervision for three months and close supervision for nine months. Supervision will be provided as outlined in the regulations. Employee #2 will be promoted to Counselor when he meets the Drug & Alcohol Counselor requirements.
Effective April 1, 2013, the Human Resources Coordinator and Clinical Supervisor will review all transcripts of potential Drug & Alcohol Counselors and Drug & Alcohol Counselor Assistants to verify that they have the required degree and/or credential prior to being hired or promoted.
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the employee personnel records, the facility failed to document the required period of supervision for two counselor assistants.
The findings include:
Eighteen personnel records were reviewed on March 4-5, 2013. Five of the eighteen personnel records reviewed were for the position of counselor assistant. Two counselor assistants did not have the appropriate documentation of supervision.
In record # 3, the employee was hired as a counselor assistant on April 16, 2012. This employee was required to have three months of direct observation and nine months of close observation. There were no supervision notes for the months of June 2012, August 2012 and September 2012.
In record # 5, the employee was transferred into the drug and alcohol activity as a counselor assistant on May 13, 2012. This employee was required to have nine months of close supervision. There were no supervision notes for the months of June 2012, and August 2012.
The findings were reviewed with the Quality and Compliance Specialist and were not disputed.
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Plan of Correction
The Clinical Supervisor developed a Counselor Assistant Supervision File Audit Tool for Treatment Supervisors to verify that Counselor Assistant supervision is being conducted weekly. The Clinical Supervisor will meet with the Treatment Supervisors on April 3, 2013 to review the Counselor Assistant supervision requirements and instructions for completing the Counselor Assistant Supervision File Audit Tool. Effective April 10, 2013, the Clinical Supervisor will conduct Counselor Assistant Supervision File audits monthly to monitor Counselor Assistant supervision compliance. The Clinical Supervisor will report results from the completed audits to the Leadership Team.
Employees #3 and #5 were identified as not receiving direct and close supervision on February 1, 2013. Employee #3 began receiving three months of direct observation on February 26, 2013 which will be directly followed by nine months of close supervision. Employee #5 began receiving nine months of close supervision effective February 6, 2013.
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709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
Based on a review of the administrative policy and procedures and a discussion with the Quality and Compliance Specialist, the facility failed to ensure the administration of medications.
The findings include:
The administrative policy and procedure manual was reviewed and discussed with the Quality and Compliance Specialist on March 4, 2013. The facility policy regarding administration of medication allows for non-medical staff members to administer medication.
The findings were reviewed with Quality and Compliance Specialist.
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Plan of Correction
On March 7, 2013, the Nurse Manager revised the Medication Administration Policy and changed the statement that non-medical staff members administer medication to the staff members supervise the self-administration of medication.
The Nurse Manager and Training Department initiated The Supervision of Self Administration Medication Training to non-medical staff on March 7, 2013. The Nurse Manager and Training Department will retrain all Abraxas I employees on The Supervision of Self-Administration of Medication by April 30, 2013. The Supervision of Self-Administration of Medication Training will also be included in all The New Hire Orientation Training for all new employees.
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