INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 14, 2006 to August 17, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on September 19, 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 # 7 has less than 1 year of clinical experience and does not meet the requirements for counselor. This individual should be listed as a counselor assistant and be under 6 months of close supervision or until the year of clinical experience has been obtained.
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Plan of Correction
704.7(b) Status of employee #7 changed to Counselor Assistant effrective 8/17/06. Supervisions being done by the Clinical supervisor. We are awaiting a copy of his degree and previous job descriptions for review. |
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
Six staff listed on the support page of the Staffing Requirements Facility Summary Report did not obtain one or the other mandatory training for either HIV/AIDS or STD/TB training within the two year time frame from the individual dates of hire.
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Plan of Correction
704.11(c) All staff have been scheduled for all required trainings and notified by memo of same. All required trainings will be completed by 1/8/06. |
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
A consent to release information form in client record #2 failed to include the purpose for the release of information. The information released in dimension 4 of the PCPC exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b). A consent to release information form in client record #4 failed to list the specific information that was to be released and Dimension 1 on the PCPC contained information that exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b) by listing the amount and type of substances the client was using. These areas make the consent to release information uninformed and involuntary.
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Plan of Correction
709.28(c) The Program Director is meeting wih all staff responsible for completing consents to review regulations and limitations by 10/1/06. Compliance will be monitored by ADON (newly admitted clients), the Clinical Supervisor (open clinical records), and Medical Records (all closed charts. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Information released in client records #2 and 4 to third party payers and/or government officials exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b).
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Plan of Correction
709.28(c)(2) The Program Director is meeting with all staff who are responsible to complete consents to review regulations and limitations by 10/1/06. Compliance will be monitored by ADON (newly admitted clients), the Clinical Supervisor (open clinical records), and Medical Records (closed charts). |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
In client records # 2 ,3, 5 and 6, two documents were reviewed for drug and alcohol histories, one history completed by the client and the other completed by the RN. The histories contained conflicting documentation, with no additional follow-up from counselor or the RN. Due to the conflicting documentation and the lack of clarification, it was not possible to determine the length and patterns of use from the documentation..
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Plan of Correction
709.5(b)(3)(ii) All Counselors will review the Nursing and Self Assessment Drug and Alcohol histories and note on the Self Assessment History any discrepancies. They will document on that Self Assessement the correct data regarding use and patterns and begin doing so by 9/15/06. |