INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 8, 2011 through February 10, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, NET Treatment Services, Inc. - NET Steps 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 March 15, 2011.
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Plan of Correction
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709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a physical plant inspection, a bed count and a discussion with the clinical supervisor, the facility failed to adhere to the authorized licensed capacity.
The findings include:
A physical plant inspection was conducted on February 10, 2011. The facility is authorized and licensed for a total of 35 beds. During the physical plant inspection, a bed count was conducted. The bed count on February 10, 2011 resulted in a total of 36 beds. During a discussion with the clinical supervisor, she admitted that there were 36 beds set up and ready to be used within the facility. However, she explained that the extra bed was to be used not for an extra client, but if a client were to become ill and would need to be quarantined in their own room. The licensing specialist informed the clinical supervisor that they can only set up the number of beds they are authorized and licensed for.
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Plan of Correction
Division Director has directed the Supervisor of Wharton Residential Program to never exceed the licensed bed capacity and that the total number of beds on site can never exceed this capacity. The Divisions PI coordinator will randomy check, without notice, the total number of beds in order to enforce compliance. |
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 and a discussion with the clinical supervisor, the facility failed to ensure each counselor met the qualifications for the position.
The findings include:
Twenty personnel records were reviewed. Twelve of those personnel records were for staff working in the outpatient clinic while eight personnel records were for staff working in the residential program. Of the eight residential personnel records, one person was hired as a counselor (#18) who did not meet the experiential qualifications for the position. Staff #18 has a Bachelor's degree in sociology, but had no clinical experience at the time she was hired.
During a discussion with the clinical supervisor, it was acknowledged that staff #18 did not meet the qualifications for the position of counselor.
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Plan of Correction
Counselor # 18 has been re-assigned to Counselor Assistant as of 2/22/11 and will receive the required amount of direct supervision by the clinical supervisor as per the state regulations. Counselor # 18's training plan has been revised to reflect this change. The Division Director will retrain HR recruitment staff of 704 staffing regulations; specific attention will be made to degrees that are acceptable prior to initiating or scheduling employment interviews. Personnel files will continue to receive a monthly audit by the quality assurance team to ensure continued compliance. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and a discussion with the clinical supervisor, the facility failed to ensure all staff receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training within the required time frame in one of twenty personnel records.
The findings include:
Twenty personnel records were reviewed. Twelve of those personnel records were for staff working in the outpatient clinic while eight personnel records were for staff working in the residential program. Of the eight residential personnel records, one personnel record (#16) did not include documentation of any HIV/AIDS or TB/STD training. Staff #16 is a counselor and was hired on 5/7/09. A minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training was due to be completed by staff #16 on or before 5/7/10. As of 2/15/11, there was no documentation of any HIV/AIDS or TB/STD training in personnel record #16.
During a discussion with the clinical supervisor she acknowledged that staff #16 did not have the required mandatory training, but that this staff person is scheduled to attend the trainings on 4/14/11.
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Plan of Correction
Counselor # 16, residential staff lacking 6 HIV & 4 STD training is scheduled for said training on 4/14/11. HR will continue to monitor personnel records on a monthly basis to ensure all staff are in compliance with regulation mandated trainings. |