INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on September 24, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Twin Lakes Center, 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:
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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 five personnel records on September 25, 2012, the facility failed to ensure that each counselor met the qualifications for the position in one of six records, as required.
Findings:
In personnel record #4, the counselor did not meet the qualifications for the position of counselor based on a Bachelor of Arts in Criminology. The employee was hired on May 17, 2010. The employee was hired for the counselor position on February 27, 2012.
The Criminology degree is not listed in the regulation or on the licensing alerts as a related degree.
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Plan of Correction
By 11/16/12, personnel record #4 will be moved to another position that is not a counseling position until they can meet the requirements of a counselor position as they are listed in the regulations. At that time, Twin Lakes Center will be compliant with the staffing regulations. In the future, it will be the responsibility of the hiring manager to ensure that the degrees of the candidates are the appropriate degrees and if there are any questions regarding degrees, DDAP will be involved. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on an onsite inspection, the facility failed to install a handrail on outside steps with more than two steps and an 18-inch drop.
The findings include:
A physical plant inspection was conducted on September 26, 2012. The second exit leading to the outside of the building has four steps and no handrail. The steps have more than an 18 inch drop.
The issue was discussed with the maintenance man during the physical plant inspection and he did not dispute the findings.
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Plan of Correction
The second exit leading out of the building will have a handrail installed by 11/2/12 by our Support Staff Coordinator. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of the facility policy and procedures, the manuals were not organized and were repetitive.
The findings include:
Several policy manuals were reviewed on September 24 th and 25 th, 2012. The manuals included documentation that was outdated and contradictory. The manuals were missing information relative to other project facilities.
The board president and the project/facility director signed on 9-20-2012 that the manual had been reviewed and updated, however the manual was not updated.
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Plan of Correction
The Executive Director will ensure that all of the policy manuals will be moved to the computerized format and will all be updated and accurate prior to 12/31/12. |