INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 16, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Parkside Recovery 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 a personnel record, the facility failed to ensure that that each counselor met the educational and experiential qualifications for the position of counselor in one of three personnel records reviewed.
The findings include:
On October 10, 2013, three personnel records were reviewed for documentation of the qualifications for the position of counselor. The facility failed to ensure that each counselor met the appropriate educational requirements for the position of counselor in one of three personnel records reviewed, specifically, personnel record # 4.
Employee # 4 is a counselor and was hired August 12, 2013. A review of the personnel record for employee # 4 indicated that the documentation for educational requirements for the position was insufficient. Based on employee # 4's transcript, employee # 4 only had a Bachelor of Science in Liberal Studies with a minor in Psychology and Speech Communication.
The findings were confirmed during an interview with the project director on October 11, 2013 at approximately 9:30 A.M.
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Plan of Correction
Employee #4 submitted a written request to employee # 4's University to identify a compatible degree based on the psychology credits on her transcript. Executive Director by November 15th will be requesting a reconsideration of employee's transcripts and reconsideration of number of years experience working in the field based on her prior work history documentation. In addition will work with employee to pursue further training if deemed necessary. In the future the agency will complete a more detailed review of any potential hire by obtaining verbal and written reference checks to assure stated experience by the applicant is accurate.
Completion Date: 11/15/13
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form completed on October 10, 2013, the facility failed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of STD/TB training and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff in one of one personnel record reviewed.
The findings include:
On October 10, 2013, one personnel record and the SRFSR form were reviewed to verify that employees had HIV/AIDS and STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff. The facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of STD/TB training in one of one personnel record reviewed, specifically, personnel record # 8.
Employee # 8 is a security guard and was hired November 22, 2010. Employee # 8 was due to complete a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training by November 22, 2012. However, personnel record # 8 did not include documentation of HIV/AIDS and TB/STD training as of October 10, 2013.
The findings were confirmed during an interview with the project director on October 11, 2013 at approximately 9:30 A.M.
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Plan of Correction
Plan of Correction: Employee # 8 has been scheduled to attend HIV/AIDS training on 11/15/2013. Employee # 8 will complete TB/STD training by 3/31/2014. Employee # 8 will submit training cerificates of completion for both trainings to the Program Director who will put documentation in employee # 8's personnel record.
All future new hires will be scheduled to receive the HIV/AIDS and STD/TB as part of their new hire program specific orientation. This will assure all new hires obtain the above stated trainings in their first year of employment with the agency. The Program Director and supervisory staff will meet quarterly and review the training records of all new hires to assure compliance with the training standards.
Completion Date: 3/31/2014
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709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on observations on October 16, 2013, the facility failed to secure client records within locked storage containers.
The findings include:
A physical plant inspection was conducted on October 16, 2013 from approximately 2:05 P.M. to 2:27 P.M. It was observed during the inspection that the discharge records' storage room # 110 was unlocked.
The findings were confirmed during an interview with the facility director on October 16, 2013 at approximately 2:28 P.M.
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Plan of Correction
Plan of Correction: At the walk through at which the records storage room #110 was found unlocked the Program Director immediately locked the storage room during the physical plant inspection. At the staff meeting of 11/8/13 the policy for the security and storage of client records was reviewed with all staff members. In addition, as part of the security officer's checklist for daily rounds securing all records storage areas is a priority item. When the rounds are complete the security officer will obtain a signature of a supervisor to assure all items on the checklist were reviewed. The supervisor will check to assure all client record areas are secured.
The Program Director and Clinical Director are responsible to assure all client records are secure.
Completion Date: 11/8/13
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