INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on January 23, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, Colonial House Outpatient was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 the review of personnel records and interview with clinical supervisor, the facility failed to ensure that each counselor met the qualifications for the position in two of two records reviewed.
Findings:
Two personnel records were reviewed on January 23, 2013. In personnel record #1, the counselor did not meet the qualifications for the position of counselor based on not having documentation of their degree or high school diploma/GED. Employee #1 was hired on November 16, 2012 as night manager but was facilitating groups and signing off on group progress notes as a counselor. Also, employee #2 was hired on July 23, 2012 and their personnel record documented a Bachelor of Science degree but the degree did not document the degree's concentration. The personnel record did not include college transcripts. There was no method to determine whether the degree qualified as one accepted by the Department. An interview with the clinical supervisor on January 23, 2013 confirmed the findings.
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Plan of Correction
Employee # 1
Concerns regarding missing documentation from personnel file for employee # 1 were addressed. A meeting was held on 1/24/13 to address High School Diploma. Citation stated that there was not a visible document in the personnel file. On the employment application employee checked that he had completed high school however; when asked to provide documentation he stated that he was in the process of obtaining a GED diploma. Employee # 1 was terminated from the position on 1/24/13 for falsifying his employment application. Correction action put in place by Colonial House Inc. All employees must produce the required documentation and credentials prior to start date of employment. The document will be submitted to the Human Resources Department with a signed release of information for verification. Upon successful verification of the documents, employee will be notified by telephone and U.S. Mail with a letter offering the position. Any potential candidate seeking employment with Colonial House Inc. that fails to do so will not be offered employment.
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709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of personnel records, the facility failed to document a job description in one of two personnel records reviewed.
The finding includes:
Two personnel records were reviewed on January 23, 2013. Employee #1 was hired November 16, 2012. During the the on-site compliant inspection, the facility failed to present a signed job description for employee 1.
An interview with the clinical supervisor on January 23, 2013 confirmed the findings.
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Plan of Correction
To correct employee # 1 not having a signed job description on file was addressed by the Program Director and Human Resources. Employee # 1 who did not have a signed job description on file was terminated due to not being able to produce a valid high school diploma of GED certificate. Colonial House Inc. has put a policy in place with Human Resources Department that upon hire all employees will be provided with a position description and will be witnessed and signed by the Human Resource Representative and employee. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on the review of personnel records and interview with clinical supervisor, the facility failed to ensure that the facility comply to PA Code 255.5.
Findings:
Two personnel records were reviewed on January 23, 2013. In personnel record #1, the counselor did not meet the qualifications for the position of counselor based on not having documentation of his/her degree or high school diploma/GED and experience. Employee #1 was hired on November 16, 2012 as a night manager but was facilitating groups and signing off on group progress notes as a counselor.
An interview with the clinical supervisor on January 23, 2013 confirmed the findings.
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Plan of Correction
Employee # 1
To correct employee # 1 not having a signed job description on file was addressed by the Program Director and Human Resources. Employee # 1 who did not have a signed job description on file was terminated from employment on 1/24/13 due to not being able to produce a valid high school diploma of GED certificate. Colonial House Inc. has put a policy in place with Human Resources Department that upon hire all employees will be provided with a position description and will be witnessed and signed by the Human Resource Representative and employee. No employee will be placed in a position that they were not hired for based on State regulations. All employees will meet all of the required regulations for the position in which they were hired.
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