INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 6-8, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Peniel Drug and Alcohol Residential Treatment Facility 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 and a plan of correction is due on August 7, 2010.
|
Plan of Correction
|
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.
|
Observations
Based on a review of five personnel records on July 6, 2010, the facility failed to ensure that each counselor met the qualifications for the position in one of five records. Findings:In personnel record #5, the counselor did not meet the qualifications for the position of counselor based on a Bachelors of Science degree in Human Resources. A review of the Bachelor of Science degree were reviewed by the Division and were found not to meet the educational component for the position of counselor.
|
Plan of Correction
This staff will pursue obtaining
her CAC certification and will be
moved to the position of Counselor
Assistant effective immediately.
The Clinical Supervisor will over-
see this project.
The qualifications for hiring future
Staff will be reviewed and approved
by Dr. Marion Spellman, CEO and
Project Director to assure that
they meet BDAP Standards.
|
705.5 (c) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(c) No more than four residents may share a bedroom.
|
Observations
Based on an on-site inspection, the facility failed to have no more than four residents in a bedroom.The findings include:Thirteen client bedrooms were viewed on June 6, 2010 at 9:30 A.M. with the Director and the Nurse on staff. The facility failed to have four or less clients residing in bed room #212. There were six clients sharing this bedroom.
|
Plan of Correction
The extra bed was removed
by the Vocational Department
while the inspector was still on
site. The Dorm Supervisor
during routine inspections
will be responsible for making
sure that this infraction
does not occur again.
|
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
Based on an inspection of the water temperature, the facility had the water temperature exceeding 120 degrees.The findings include:The hot water temperature was reviewed on June 6, 2010 at approximately 9:15 A.M.. After an on-site temperature was taken in the presence of the director and licensing staff, it was determined that the hot water temperature exceeded 120F. The temperature was 140 degrees.
|
Plan of Correction
A new water heater that meets
BDAP standards has been
purchased and installed.
The Vocational Director will be
responsible for monitoring
all of the water heaters in the
facility by regularly checking
the temperature gauge.
|
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
|
Observations
Based on observation, the facility failed to store utensils in an enclosed area.The findings include: An on site inspection of the kitchen was made on June 6, 2010 in the presence of the Director and a nurse on staff. During this inspection it was observed that the facility failed to cover the utensils between meals. After an interview with the staff in charge the kitchen, it was determined that the policy was never put in place and it was not an oversight for that day.
|
Plan of Correction
The silverware was covered while
the inspector was still on site.
The Culinary Director will oversee
placing a cellophane cover over
all of the silverware to assure
sanitary procedures are consistently
maintained.
|