INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 17 - 18, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Drug and Alcohol Services of Beaver Valley, 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
The facility failed to document that all counselors met the qualifications for the position.
Employee #7 was hired as a counselor on June 11, 2019. He holds a Master's Degree in Business Management. This degree is not on our approved list.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.7 (b)
Counselor Qualifications
On 12/24/19, Counselor 7 signed a job description confirming his status as Counselor Assistant. Counselor 7 will remain a counselor assistant until he graduates with his Master's Degree in counseling from California University of PA. Clinical Supervisor, will devise a of schedule weekly supervisory meetings with counselor assistant to be implemented by 01/15/20.
Additionally, all counselors hired will meet the Department's educational requirements before employment begins. The Clinical Supervisor and Executive Director will monitor applicant's resume and transcripts to insure compliance before permitting the employee to begin working. |
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
The facility failed to document at least 25 hours of training annually for each counselor.
Employee #3 was hired as a counselor on February 2, 2015. Employee #3 had 0 hours of training documented for the July 1, 2018 - June 30, 2019 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.11 (f) (2)
Training Hours Required- Counselor
Counselor 3 will develop, sign and present a training schedule for 25 credits to Executive Director and Clinical Supervisor by Feb. 3. 2020. If counselor 3 fails to follow through with attending required trainings, Employee 3 will be terminated at the end of DASBV's training year on June 30, 2019
Moving forward, The Clinical Supervisor and Executive Director will monitor each staff member's training hours on a quarterly basis. All counselors will complete the required training hours per Department regulations. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to file an unusual incident report with DDAP within 3 business days following an unusual incident involving ambulance personnel.
An incident occurred on November 27, 2019 in which ambulance was called to facility. No documentation that incident report was sent to DDAP.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.34 (c) (4)
Reporting of Unusual Incidents
On 12/19/2019, DASBV Executive Director enrolled in the Department's Website and uploaded the incident report dated 11/27/2019 as instructed.
Any future incidents will be uploaded within 3 days, as per Department Rules. The Executive Director will upload data; if unavailable, the Clinical Supervisor will upload report. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to review and update treatment plans at least every 60 days.
Client #3 was admitted on January 14, 2019 and discharged on November 15, 2019. The preliminary treatment plan was completed on January 14, 2019. There were no other treatment plans documented in client record #3.
Client #4 was admitted to treatment on October 9, 2018. A treatment plan update was documented on July 9, 2019. Treatment plan updates were due to be completed by September 9 and November 9, 2019. One treatment plan update, dated September 19, 2019 was documented in client record #4.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92 Treatment rehabilitation Services
All files are to become centrally located on the first floor No files are to be kept in counselor offices any longer. These files will be reviewed by the Clinical Supervisor on a weekly basis to insure that treatment and rehabilitation plans will be reviewed and updated at least every 60 days. This will be implemented by 01/15/2020 |
709.93(a) LICENSURE Client records
709.93. 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:
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Observations
The facility failed to document a complete client record which included progress notes, case consultation notes, aftercare plans, discharge summaries and follow up information.
Client #1 was admitted on April 1, 2019 and discharged on November 5, 2019. The last progress note documented was dated July 17, 2019; however, per the record of service, the client was seen at least 5 times after July 17, 2019. There was also no discharge summary or 30 day follow up documented as per agency policy in client record #1.
Client #3 was admitted on January 4, 2019 and discharged on November 15, 2019. The last progress note documented was dated May 21, 2019; however, per the record of service, the client was seen at least 12 times after May 21, 2019. There was also no case consultations, aftercare plan, discharge summary or 30 day follow up documented as per agency policy in client record #3.
Client #4 was admitted on October 9, 2018. The last progress note documented was dated April 4, 2019; however, per the record of service, the client was seen at least 16 times after April 4, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.93 (a) Client Records
All files will be centrally located on the first floor and no longer kept in the counselor's offices. These files will be reviewed for compliance by the Clinical Supervisor on a weekly basis starting 01/15/20.
Additionally, our client files have been revised to that the Record of Service, signed by the client, and the Case Notes, drafted by the counselor, will be opposite each other for easier viewing thereby eliminating opportunities for confusion of dates and requirements. This file revision started on 12/31/2019
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