INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 28, 2006 to August 29, 2006 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 September 26, 2006.
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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 number 1 has an administration of justice degree that does not meet the requirements of a human service related field.
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Plan of Correction
704.7 (b) Licensure Counselor Qualification:
Employee, Curtis Melton, has a Bachelor's Degree in Criminal Justice,
however lacked sufficient number of psychology credits to support the position for a D&A counselor. He is currently pursuing his master's degree in Criminal Justice Management,
with a projected graduation date December 2007. He will remain in a counselor assistant position
and be directly supervised by a counselor or clinical supervisor for the initial 3 months.
The following 9 months he will counsel under the close supervision of a lead counselor or a clinical supervisor.
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) 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"Financial Agreement Form" incudes a general consent to release information. The agreement gives a general consent to release information to insurance companies. Although the form does restrict the information for the drug and alcohol patient, the form does not meet the requirements as identified in 42 CFR Part 2, Subpart C, Subsection 2.32 and 42 CFR Part 2, Subpart C, Subsection 2.31 and at 28 Pa. Code Subsection 709.28(c) through (c)(6) and 709.28(d).
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Plan of Correction
The Financial Agreement form has had further clarifying statement added.
FINANCIAL AGREEMENT
Consumer: BSU#: Agency #:
CONSENT TO BILL:
I agree that the information given by me in applying for payment and service is correct.
- I understand that payment for these services may be made from Federal and State funds. I understand that I may be criminally liable for any false statements I make, any false documentation I provide, or any information that I conceal.
- I authorize the Provider to release medical and any other information to payers needed for payment of any bills, with the exception of Drug and Alcohol Services which allow only the release of type of program, summary of progress, frequency of relapse, and prognosis with an appropriate informed signed consent from the client.
AGREEMENT FOR PAYMENT:
- I agree to pay the Provider for services performed.
- I agree to pay any unmet insurance deductibles and/or co-payments.
- I agree that I will sign over any checks that I receive from the insurance company. Payment for services may be made by either personal check or by endorsing the insurance payment by writing, "Pay to the Order of Home Nursing Agency" with authorized signature.
- I agree that I will be responsible for all charges, in the event there is no insurance coverage.
- I agree that I will pay in full in 30 days.
- I have been informed of charges for the services.
- The figures and amounts represented below are only an estimate of anticipated charges. It is impossible to predict the total cost of services before they are provided. The amounts listed below are based on information supplied from the insurance companies and other payment sources that I have given to the Provider.
- The total amount of anticipated charges will depend upon the number of service(s) during the treatment. Any changes in the frequency will be communicated to me.
PAYMENT FOR OTHER SERVICES:
Service Provider Charge Per Visit/Unit Payment Anticipated From: (Amount can be $ or %)
Source Amount Source Amount Source Amount
1. ASSESSMENT HNA Consumer
2. HNA
3.
4.
After all other payment sources have been exhausted, County MH/MR/D&A Office may pay for a portion of the cost of services. If this happens, I will be responsible for paying _______________________ per hour OR per month (circle one).
Signature of Consumer/Person Responsible for Payment Date
Billing Address (if different from consumer) Witness Date
I give my consent for the Home Nursing Agency to contact me regarding my treatment and payment for my treatment. I may be contacted by:
Mail, including bills, sent to my home (outside envelope will indicate from Home Nursing Agency; not specific program)? Yes No
Telephone calls to my home? Yes No
Telephone calls to my office? Yes No
Messages left on my home answering machine (only the staff's name, time of call, and request to return the call)? Yes No
Messages left with the person who answers the telephone (only the staff's name, time of call, and request to return the call)? Yes No
Signature of Consumer/Person Responsible for Payment Date
Billing Address (if different from consumer) Witness Date
WHITE - Record YELLOW - Business Office PINK - Consumer
Form #683 © Home Nursing Agency Revised 9-12-06 FinancialAgreement/ew/msw/d4
ase
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