INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on April 26, 2010 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site inspection, Pathway Counseling Services 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 May 28, 2010.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records and an interview with employee #1, the facility failed to insure that the staff person appointed to the position of facility director met the educational requirement.
The findings include:
Three personnel records were reviewed. All personnel hired by the project were required to meet the educational requirement. Employee #1 lacked the educational requirements for the position of facility director. The documentation indicated that employee #1 has a high school diploma and a current Certified Addictions Counselor (CAC) certification.
An interview with employee #1 was conducted on April 26, 2010 at which time employee #1 confirmed that she should have been documented as lead counselor.
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Plan of Correction
The staff person appointed to the position of facility director is Drew Alikakos, M.S., Licensed Psychologist. He meets all the educational requirements necessary for a facility director. Employee #1 is the lead counselor. This has been documented in the personnel records of Pathway Counseling Services. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on the review of administrative documentation and an interview with the facility director, the facility failed to document an independent annual audit of financial activities associated with the project's drug and alcohol abuse services.
The findings include:
The facilities administrative documentation was reviewed and an interview with the facility director was conducted on April 26, 2010.
The facility was required to document an annual audit of financial activities.
The facility did not document an annual audit for the year 2008-2009 fiscal year.
The facility director confirmed that a financial audit had not been completed.
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Plan of Correction
The faciltiy director will ensure that an annual audit of financial activities for the 2008-2009 fiscal year will be completed by August 1, 2010 by independent accountant that does not work for Pathway Counseling Services. The facility director will document in the facilities administrative records that an indepentdent annual audit of financial activities will be performed each year for Pathway Counseling Services by an independent accountant that does not work for Pathway Counseling Services. The facility director will follow up to ensure that the audit is completed annually in a timely manner. |
709.29(a) & (b) LICENSURE Retention of Client Records
709.29. Retention of client records.
(a) Client records, whether original, reproductions or microfilm, shall be kept on file for a minimum of 4 years following the discharge of a client.
(b) If the project discontinues operation, it shall make known to the Department where its records are stored.
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Observations
Based on the review of the policy and procedures manual and an interview with the facility director the facility failed to provide client active and discharge records for a minimum of 4 years following the discharge of a client.
The findings include:
The facilities policy and procedures manual was reviewed and an interview with the facility director was conducted on April 26, 2010.
The facility was required to provide an active and discharge client list. The facility provided an active and discharge list that began in November 2009.
The facility director confirmed their practice of maintaining client records for 6 months at which time they are shredded.
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Plan of Correction
The facility director will keep client active and discharge records for a minimum time period of four years. The policy and procedures manual has been documented to reflect this change as of May 24, 2010. |