INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 5-6, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Deerfield Center for Addiction Treatment 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 5, 2011.
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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 one personnel records.
The findings include:
On April 5, 2011, eight personnel records were reviewed. One personnel record was required to have documentation of the qualifications for the position of counselor. The facility failed to ensure that employee #4 met the qualifications for the position of counselor.
Employee # 4 has an Associates in Science degree in Human Services but does not have the required two years of experience. Therefore, employee #4 does not meet the experiential requirements for the position of counselor.
This was discussed with the supervisor on April 5, 2011, and it was confirmed by the supervisor that this counselor does not meet the qualifications.
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Plan of Correction
Employee # 4 will maintain the status as a counselor assistant until he has meet the supervision requirements as stated in Chaptor 704.9 (c) 4. The clinical supervisor will provide a written semiannual performance evaluation, provide direct observation, and documentation of supervision. This should be accomplished within 9 months. |
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, a review of the facility summary report, and a conversation with the supervisor, the facility failed to provide documentation of HIV/AIDS and TB/STD training for one of one personnel.
The findings include:
Eight personnel records were reviewed on April 5, 2011. The facility summary report was reviewed on April 5, 2011. Seven personnel were required to have documentation of HIV/AIDS and TB/STD training. One personnel record is still within the time frame for completion for the HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and TB/STD training for personnel record # 5.
Employee # 5 - HIV/AIDS and TB/STD training was to be completed within one year of hire, by July 20, 2010. The facility failed to provide documentation of HIV/AIDS and TB/STD training for this employee as of April 5, 2011.
This was discussed with the supervisor on April 5, 2011. The supervisor confirmed that the HIV/AIDS and TB/STD training was not completed by employee # 5.
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Plan of Correction
The clinical supervisor will see that the staff member will have completed the BDAP approved HIV/AIDS and TB/STD training. The staff member is scheduled to completed all training by May 15, 2011. The program director will check to see that there is documentation indicating completed training. |
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 fire drill logs and an interview with the treatment supervisor and the maintenance staff, the facility failed to provide documentation that the fire alarm or smoke detector was tested.
The findings include:
The fire drill logs were reviewed on April 5, 2011. Per regulation, the nonresidential facility shall set off a fire alarm or smoke detector during each fire drill. The fire drill log was reviewed for documentation of fire drills from the time period of April 2010 to March 2011. The facility has an exception dated August 18, 2005 to allow the facility to not activate the system during each fire drill, but to test the system and provide documentation of that testing. The facility failed to provide the documentation that the system was tested.
The treatment supervisor and the maintenance staff, confirmed that there is no documentation of the system testing
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Plan of Correction
The Fire Safety system in this building is designed as a "self-testing" system. To ensure that it is in working order, the building maintenance worker will set off the fire system two time each year. The results of this procedure will be documented in the Fire Drill Log. The maintenance worker has been informed of this procedure and will conduct the first system test at the time of the next fire drill. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records and an interview with the supervisor, the facility failed to document annual performance evaluations as required by agency policy and regulation in three of five personnel records.
The findings include:
Eight personnel records were reviewed on April 5, 2011 Five personnel records were required to include documentation of annual performance evaluations. Per agency policy, performance evaluations are conducted at six months and annually thereafter. There were no annual performance evaluations documented in personnel records #1, 2, and 3.
Employee #1- An annual work performance evaluation was due in October 2010, and was not documented as of April 5, 2011.
Employee #2- An annual work performance evaluation was due in June 2010, and was not documented as of April 6, 2011.
Employee #3- A six-month work performance evaluation was due in November 2010, and was not documented as of April 5, 2011.
This was discussed with the supervisor on April 5, 2011. The supervisor confirmed that the work performance evaluations were not completed.
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Plan of Correction
The program director will work with personnel to create a process to insure that performance evaluations are completed within 30 days of the employees anniversary date. This process will be implemented within 15 days. The program director will oversee this process and check to see that evaluations are completed on time. |