INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 11, 2007 to June 12, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on July 17, 2007.
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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
Employee #3 did not have the required experience dictated by the level of education. The facility also failed to provide documentation of the major for employee #3.
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Plan of Correction
PM will provide direct observation and supervision on a weekly basis for Employee #3's first 6 months. Also, PM has obtained her official transcripts which indicate her major as social work. From now on, PM will ensure that future candidates will provide documentation showing the necessary requirements prior to hire. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
The project failed to provide an evaluation of the 2005/2006 overall training plan.
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Plan of Correction
PM will complete the training plan according to program policy. PM will also insure going forward that all computerized information/reports are have multiple back ups to avoid accidental erasure. |
705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
There was only one ABC rated fire extinguisher for approximately 3800 square feet.
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Plan of Correction
PM to obtain and place sufficient number of extinguishers in program suite at appropriate locations as determined by Drexel Fire Safety officer. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
The program failed to provide documentation of staff receiving fire extinguisher training.
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Plan of Correction
Obtain necessary training for all staff and PM will now train new employees going forward. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations were a repetition of client's historical data rather than an evaluation by the counselor in two of four client records reviewed, #1 and 4.
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Plan of Correction
PM to retrain all staff who perform biopsychsocial evaluations to correct implementation and add prompts to evaluation form to further guide staff. PM will also do regular monthly spot checks to evaluate compliance. |
711.92(c)(1) LICENSURE TX Plan Goals
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
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Observations
The facility failed to provide individualized treatment plans in four of four client records reviewed, #1, 2, 3 and 4 . These treatment plans contained identical and standardized goals and objectives that were not based on each client's individual needs.
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Plan of Correction
Staff person will be retrained by PM with regard to individualized treatment plans and monitored monthly thereafter to check compliance. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
The program is using consent forms to obtain information in six of six records reviewed.
Client record #4 had all consents to obtain without benefit of a corresponding consent to release information.
Client record #6 failed to provide documentation that an informed, signed consent to release was obtained prior to the release of information to the court evaluation unit.
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Plan of Correction
Caring together will no longer use consents to obtain per the evaluator's direction. PM will reiterate in staff meetings the importance of insuring all necessary forms are completed. Program does not disclose information without a signed consent - employee who was responsible for record #6 is no longer with agency. |
711.93(c)(2)(iii) LICENSURE Purpose of Disclosure
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(iii) The purpose of disclosure.
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Observations
Consents to release forms in five of five client records reviewed, failed to include the purpose of the disclosure or had an inaccurate purpose for the person or agency receiving the information.
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Plan of Correction
PM to discontinue practice of using "standard language" regarding purpose of release on some release forms and re-train staff. PM will also reiterate in staff meetings the importance of insuring all necessary forms are completed in full. |