INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 12-13, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Summit Academy 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 qualifications for the position in two of seven personnel records.
The findings include:
On August 12-13, 2013, twenty three personnel records were reviewed. Seven 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 #4 and 5.
Employee # 4 was hired as a counselor on May 5, 2013. Employee # 4 has a Bachelor of Arts degree in Administration of Justice and a Master of Arts degree in Criminology. Employee #4 has no clinical experience and did not complete a practicum for the Masters degree. Employee #4 does not have the required experience to meet the counselor qualifications
Employee # 5 was hired as a counselor on May 20, 2013. Employee # 5 has a Master of Science degree in Psychology. Employee # 5 has no clinical experience and did not complete a practicum for the Masters degree. Employee #5 does not have the required experience to meet the counselor qualifications.
An interview with the Human Resource manager took place on August 13, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
Beginning August 30, 2013, in addition to verifying credentials of clinicians prior to hire, the company has added the following to the procedure by which the credentials of potential employees are verified: 1.) In the event that a candidate has a Master's Degree, the company will verify that an appropriate practicum has been completed and is documented on the official transcript; 2.) The company will verify that appropriate clinical experience occurred.
Regarding those employees who are already in the employ of the company, the company will conduct a three- month supervision with these staff and provide written documentation that the supervision has taken place. This will be completed by a Clinical Supervisor. Upon the completion of the three- months a formal letter will be place in the staff member's personal file to indicate the staff is competent to maintain a caseload without supervision. This began September 2, 2013
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