INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 14, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Services of Beaver Valley Inc. 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 three personnel records.
The findings include:
Seven personnel records were reviewed on October 14, 2015. Three personnel records were required to have documentation of the qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel record # 5.
Employee # 5 was hired as a counselor on September 16, 2015. There was no documentation provided to verify the employees degree and major. The copy of the employee's transcript documented in the personnel record could not be read.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All new hires will be asked to bring a complete set of credentials/degrees to the initial interview. A new hire will not be given a start date until all credentials are received and approved by the Executive Director. The effective date for this procedure will be November 1, 2015. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form completed by the facility on October 6, 2015, the active clients by therapist list provided by the facility and an interview with the Project/Facility Director, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on October 14, 2015. The form listed 8 counselors, a clinical supervisor and project director/ facility director as clinical staff . The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.
Based the total number of hours per week that the facility reported the employee devoted to their clients, the total number of hours in the facility's standard work week 40, and the total number of clients assigned to the following employee on October 14, 2015, employee # 8 exceeded the allowable maximum 35:1 caseload.
The number of hours per week devoted by Employee # 8 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 40 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee #8 had 43 active clients on October 6, 2015. The active clients by therapist list provided by the facility on October 14, 2015 listed that employee # 8 had 53 clients, 43 of which were active clients.
Employee # 8 40/35 =1.14 FTE 43 clients/1.14 FTE = 38:1 ratio.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to ensure program compliance in maintaining a 35:1 ratio the Clinical Supervisor will post the daily active client report by counselor. Each counselor will be able to review his caseload numbers and take corrective action if needed. The Clinical Supervisor will also email each counselor that exceeds the 35:1 ratio, requesting a plan of action to bring their caseload into compliance. The Clinical Supervisor will be responsible for monitoring this standard. Full compliance will be attained by November 30,2015.
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