INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18, 2007 and September 19, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Casa De Consejeria Drug and Alcohol Counseling Program, 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 October 11, 2007.
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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 personnel records it was determined that the agency failed to provide verification of counselor qualifications. Two of two personnel files reviewed on September 18, 2007 failed to include either a transcript or a degree in order to determine compliance with staffing requirements. A counselor hired on September 30, 2007 has degree is in Liberal Arts without a transcript and a counselor hired on September 5, 2007 has a degree in an unrelated field.
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Plan of Correction
The Program Director sent trascript and resume for Y.L. who was hired on 07/30/07, not on 9/30/07 as stated in the report. Documents were reviewed by Supervisor Review of the Division of Drug and Alcohol on 09/26/07 and it was determined that she qualifies for the position of Counselor Assistant.However, she will resign to her position effective October 22,2007.
The Program Director sent trancript and resume for H.N.,who was hired on 9/5/07 as Counselor. Documents were reviewed by Supervisor Review of the Division and it was determined that he qualifies for a technician level. The Program Director will resend the documents along with degree for final determination. |
704.8(a) LICENSURE Qualifications-Counselor Assistant
704.8. Qualifications for the position of counselor assistant.
(a) A person who does not meet the educational and experiential qualifications for the position of counselor may be employed as a counselor assistant if the requirements of at least one of the following paragraphs are met. However, a project may not hire more than one counselor assistant for each employee who meets the requirements of clinical supervisor or counselor.
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Observations
Based on a review of administrative and personnel documentation it was determined that the facility failed to limit the number of counselor assistants to the same number of clinical supervisors and counselors. A review of four personnel files, staffing requirements facility summary report and an interview with the project director and clinical supervisor on September 19, 2007 further verified one qualified clinical supervisor and four counselor assistants have been hired since the prior survey of January 4, 2007.
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Plan of Correction
One of the four counselors assistant will resign to the position effective October 22, 07. The Program Director will provide supervision to one of the counselor assistant,as well as the Clinical Supervisor will provide supervision to the second one. The third clinician will be evaluated by the Staffing Qualifications Review Unit of the Drug and Alcohol Division to determine qualifications as counselor. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on staff interviews and a review of personnel records it was determined that the facility failed to provide verification and documentation to assure the counselor assistant hired on April 3, 2006 is working toward counselor status. A review of the counselor assistants personnel file, training file, training plan and an interview with the project director and clinical supervisor on September 19, 2007 failed to produce verification of the counselor assistants effort on working toward counselor status.
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Plan of Correction
The Clinical Supervisor will develop a plan along with counselor assistant to provide verification and documentation that he'll work toward the counselor status. Prior information was provided to the counselor assistant, by Program Director. Verbal agreements were in existence, but not written documentation. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of administrative documentation and the fire drill log it was determined that the facility failed to provide verification of fire alarm or smoke detector activation during monthly fire drills. A review of the fire drill log on September 19, 2007 for the period of January 2007 through August 2007 revealed that documentation of system activation had not been entered in the log.
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Plan of Correction
The Administrative Assistant will provide verification on the fire drill log about the activation of the smoke detector. |
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
Based on a review of client records it was determined that the facility failed to obtain consent for the disclosure of information to Community Behavioral Health and to Behavioral Health Service Initiative for funding of outpatient activities. In eight of eight client records reviewed on September 19, 2007, consent for the disclosure of client information had not been completed.
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Plan of Correction
The Clinical Supervisor will conduct an orientation with the clinical staff to inform them about the immediate need of having available the consents for the Community Behavioral Health's medical insurance anf for Behavioral Health Service Initiative. Program Director will oversee the conduction of activity. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records it was determined that the project failed to assure counseling services are provided according to the individual treatment and rehabilitation plan. A review of eight of eight client records on September 19, 2007 verified treatment and rehabilitation plans with group counseling one time a week defined in the type and frequency of services. Eight of eight clients records reviewed did not have a record of service or progress notes to verify group counseling activities occurred weekly as defined in the plan. An interview with the project director and clinical supervisor on September 19, 2007 provided further verification that group counseling activities are not provided according to the individual treatment and rehabilitation plan.
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Plan of Correction
Clinical Supervisor will provide an on-site training to counselors to inform them about the importance of client's treatment commitment not only for individual counseling , but for group counseling. The counselor will document the treatment plan and the progress notes based on treatment agreement with client. This training activity will be documented by Clinical Supervisor and it will be overseen by Program Director. |
709.93(a)(2) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(2) Medication records.
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Observations
Based on a review of client records it was determined that the project failed to document medications taken by a client in two of three client records reviewed on September 19, 2007. Client record number 1 and client record number 2 did not include documentation of the drug, dosage and frequency of medication prescribed by the client's physician.
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Plan of Correction
Clinical Supervisor will provide an on-site training to discuss with counselors the importance of having documention about the drug, dosage and frequency of medication prescribed by the client's physician. Clinical Supervisor will document the conduction of such clinical training. Clinical activity will be overseen by Program Director. |