INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 21, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pyramid HealthCare Inc. 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 six personnel records, it was determined that one of three applicable counselors did not have the 1 year of clinical experience required to qualify for the position.
Employee #4 was hired as a counselor on November 29, 2021 and is still current in that position. Employee #4 did not have the 1 year of clinical experience required to be a counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will submit corrected resume reflecting correct work experience will be sent electronically to Human Resources Department by 08/08/2022 for Counselor #4's employee file to be corrected and in compliance with regulations.
Executive Director will ensure all future counselor candidates being considered for hire, have their resumes and/or transcripts submitted for qualifications review by licensing agency. Executive Director will submit these applicants for review electronically to licensing agency and await results of review before a job offer is extended to a candidate.
Upon receipt of approval Executive Director will ensure this resume and/or transcripts are sent to the appropriate Human Resources representative to be added to employee's electronic employee file. Executive Director will also keep a file onsite for each employee with all penitent documentation regarding qualifications including but not limited to, resumes, transcripts, and training certifications.
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection on July 21, 2022, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room as all counseling offices and three group rooms had doors with windows that were not covered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure facility is providing private and confidential areas for clients, facility will cover all office and group room windows noted deficient during inspection completed on July 21, 2022. Facility Director has placed supply order for window coverings on July 22, 2022. It is anticipated these supplies will be delivered to facility on July 27, 2022. Once these supplies are obtained, window coverings will be completed by maintenance department on or before August 12, 2022. |