INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 17, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on June 18, 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
The project failed to employ qualified staff. Employee #1 did not have a degree in a related human services field and did not qualify for the position.
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Plan of Correction
Employee #1 had a Masters Degree in Health Education, which is not recognized by the State auditor. The employee will change job description by 6/15/2007 to Counselor Assistant, since thay are working on obtaining full CAC by December of 2007. Effective 6/15/2007, The Site Director of NE office, Bonnie Heine, will supervise the employee under guidelines contained in state standard 704.9 for Counselor Assistants. The employee will provide documentation of full CAC by 12/2007 & give to the NE site director upon completion. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
In two of two staff training files reviewed the organization failed to provide first aid training to a sufficient number of staff persons so that at least one person currently certified was onsite during the hours of operation.
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Plan of Correction
The site did not have updated first aid training, most all staff had expired dates on the last first aid training attended. Two staff (one day shift/one eveing shift)from the Northeast site will register & complete a current first aid training within the next three months at local YMCA and/or medical facility. The site director will ensure that staff complete training within stated time frames. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Employee #4, as listed on the staff summary report, failed to meet the twenty-five hours of training for training year 2006.
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Plan of Correction
Employee #4 had restrictions on driving to outside trainings due to a medical condition; so only on-line trainings could be documented. In 2007, this employee has been medically cleared to drive again. The site director of Northeast office will monitor this employee on a monthly basis during 2007 to ensure that 25 hours of training will be documented - 12 of these hours can be obtained through trainings presented at the Northeast office. The site director will review 2007 training plan with employee by 6/30/2007 & record enrollment in both in-house & outside trainings. If hours are not met, then employee will be placed on probationary status. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The project director failed to establish project goals and objectives with time frames and available resources. A review of governing body information, to include board meeting minutes and quarterly reports, failed to include the necessary documentation.
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Plan of Correction
The president/projrct director stated project goals and included in the governing body minutes, but without specific goals and time frames included in the report. The president/project director & administrative manager will write down specific objectives with quarterly time frames reported/included by 6/21/2007. These will also be documented & included in the 2007 Governing Body report after approval from Governing Body by 6/30/2007. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
A review of the organizations treatment management plan and letters of agreement failed to document an agreement for 24 - hour emergency medical coverage.
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Plan of Correction
A letter of agreement with Frankford Hospital was not current & did not include the wording - 24 hour medical emergency coverage in the documentation. A revised referral agreement with wording specific to include 24 hour emergency medical coverage will be sent out by 6/30/2007. The Site Director of Northeast will monitor progress on this monthly & place in the current referral agreement log when it is recieved at the facility.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Case consultation notes were not completed on 90 day basis and were missing in three of four client records reviewed, client records # 3, 5 and 6.
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Plan of Correction
Three client records did not have case consults documented in the charts by assigned counselor. The site director of Northeast, Bonnie Heine, will provide a training on case consultations by 7/30/2007. This training will include how to document a consult on the client's chart & within the standard time frame of 90 days. All Northeast staff will sign off that they have attended the training & understand the standard. The site director will audit charts on a monthly basis until the site is in full compliance. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Client record numbers 6 and 8 did not include documentation of an aftercare plan as defined in project policy statements.
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Plan of Correction
Two client records did not have proper aftercare documentation. The site director of Northeast will provide an in-service training by 8/15/2007 with all Northeast counselors. This training will include a review on documentation of aftercare plans in accordance with Rehab After Work clinical manual & the state standards. All staff will complete training & sign off that they understand the standard. The site director will randomly audit charts on a monthly basis until the site is in full compliance. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Client records number 6 and 7 were not complete. Follow-up contact relative to the clients involvement with the project was missing and not documented as defined in the project policy.
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Plan of Correction
Two client records did not contain proper follow-up contact attempt by the counselor of record. The site director of the northeast office will provide an in-house training regarding follow-up documentation by 7/30/07 at the Northeast site. Documentation guidelines as outlined in RAW treatment manual will be reviewed. All staff will complete the training and sign off that they understand the standard. The site director will pull random charts to audit on a monthly basis until the standard is in full compliance. |