INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 18 - 19, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Stairways Behavioral Health Outpatient Drug and Alcohol 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.
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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, the facility failed to ensure that each counselor met the qualifications for the position in one of four personnel records.
The findings include:
On April 18, 2012, six personnel records were reviewed. Four of the six personnel records were required to include documentation of the qualifications for the position of counselor.
Employee # 2 was hired as a counselor on 9-26-2011. Employee #2 has a Bachelor of Science is Psychology which meets the educational requirements; but does not have one year of clinical experience. Employee # 2 only has seven months of clinical experience which does not meet the minimum requirements for the position of counselor.
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Plan of Correction
Supervisory notes for employee #2 were submitted and reviewed by inspector during site visit. Employee #2 has signed a job description indicating her status as a counselor's assistant. Employee #2 will continue to have regular clinical supervision until she reaches one year of clinical experience, when she will be eligible for regular counselor status. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update within 60 days of the comprehensive treatment plan in four of eight client records.
The findings include:
Ten client records were reviewed on April 19, 2012. Eight client records were required to include documentation of a treatment plan update. Per the facility policy, treatment plan updates are required to be completed within 60 days of the comprehensive treatment plan. The facility failed to document a treatment plan update in client records #3, #4, #5 and #10.
Client record #3 - The client was admitted on September 29, 2011. The comprehensive treatment plan was completed on October 25, 2011. Treatment plan updates were due by December 25, 2011 and February 25, 2012. The facility failed to document the completion of the December 25, 2011 and February 25, 2012 treatment plan updates.
Client record #4 - The client was admitted on November 17, 2011. The comprehensive treatment plan was completed on December 16, 2011. A treatment plan update was due by February 16, 2012, but was not documented until February 27, 2012. The facility failed to document the completion of a treatment plan update within the 60 day time frame.
Client record #5 - The client was admitted on January 26 2012. The comprehensive treatment plan was completed on February 1, 2012. The treatment plan update was due by April 1, 2012, but was not documented until April 16, 2012. The facility failed to document the completion of a treatment plan update within the 60 day time frame.
Client record #10 - The client was admitted on August 8, 2011, and discharged on February 15, 2012. The comprehensive treatment plan was completed on August 19, 2011. The treatment plan update was due by October 19, 2011, and was documented on October 12, 2011. The next treatment plan update was due by December 19, 2011, but was not documented until January 19, 2012. The facility failed to document the completion of a treatment plan update within the 60 day time frame.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
Treatment plan reviews will be completed on all cases that were missing them. Reports have been developed to provide monthly due dates for upcoming treatment plan review, which will prevent ongoing issues with missing or late documentation.
Facility Director and Lead Counselor will monitor completion of documentation. |
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
Based on a review of client records, the facility failed to document a case consultation within the quarterly time frame in three of eight client records.
The findings include:
Ten client records were reviewed on April 19, 2012. Eight client records were required to include documentation of case consultations. Case consultations are due quarterly. The facility failed to document case consultations in client records #3, #4, and #10.
The findings include:
Client record # 3 - The client was admitted on September 29, 2011. The case consultations were due December 29, 2011 and March 25, 2012. The facility failed to document the completion of the December 29, 2011 and March 25, 2012 case consultations.
Client record # 4 - The client was admitted on November 17, 2011. The case consultation was due February 17, 2012. The facility failed to document the completion of the February 17, 2012 case consultation.
Client record # 10 - The client was admitted on August 8, 2011, and discharged on February 15, 2012. The case consultations were due November 8, 2011 and February 8, 2012. A case consultation was completed October 26, 2011. The facility failed to document the completion of the February 8, 2012 case consultation.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
Case consultations were completed on cases that were lacking notes.
A report has been generated that will track monthly due dates for case consultations that are pending to prevent further issues with late and/or missing documentation
Facility Director and Lead counselor will provide monitoring of completion of case consultations with assistance of tracking report.
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