INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 20, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, NorthEast Treatment Centers, 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 the review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of four record reviewed.
Findings:
Sixteen personnel records were reviewed on November 18, 2014. Employee #4 was hired on December 16, 2013 and did not meet the qualifications for the position of counselor based on his Doctorate degree in Philosophy, Master Degree in Business and Bachelor's degree in Natural Science.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director has reclassified employee #4 to Counselor Assistant as of December 8, 2014. A position description matching the title of Counselor Assistant has been completed and filed in the personnel file by the Clinical Supervisor. Clinical Supervisor began monitoring and supervising employee #4 as of December 8, 2014 as per the state regulations regarding supervision over the Counselor Assistant. Human Resources Director will review all incoming employees credentials so as to properly identify their title based on credentials. The Program Director will review the personnel files monthly to ensure all new hires have the appropriate title and job description based on regulatory standards for the position noted. |
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, the facility failed to provide documentation of HIV/AIDS and TB/STD training in three of sixteen personnel records reviewed.
The findings include:
Sixteen personnel records were reviewed on November 18, 2014. Three personnel records were required to have documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and TB/STD training in personnel records # 14, 15 and 16.
Employee # 14, a counselor, was hired November 11, 2013. HIV/AIDS and TB/STD training was due to be completed no later than November 11, 2014. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of the date of this inspection.
Employee # 15, a counselor, was hired September 16, 2013. HIV/AIDS and TB/STD training was due to be completed no later than September 16, 2014. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of the date of this inspection.
Employee # 16, a counselor, was hired September 9, 2013. HIV/AIDS and TB/STD training was due to be completed no later than September 9, 2014. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of the date of this inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will coordinate a scheduled TB/STD and HIV/AIDS training to be conducted where Employees #14, 15 and 16 will attend. The TB/STD and HIV/AIDS training are scheduled for January 22, 2015 and January 27 2015 respectively. The Program Director will review and monitor personnel files monthly to ensure all employees receive TB/STD and HIV/AIDS training within one year or hire date to avoid future infractions regarding licensure standard 704.11. TB/STD and HIV/AIDS trainings will be scheduled accordingly, by the Program Director to meet the training requirements for this standard. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consents in two of ten records reviewed.
The findings include:
Ten client records were reviewed on November 19, 2014. All were reviewed for informed and voluntary consent forms. The facility failed to document informed and voluntary consents in two client records, specifically record, #3 and 6.
Client #3 - The facility failed to document what was being release on the consent to release dated June 10, 2014 to an agency.
Client #6 - The facility failed to document the date when staff signed the consent to release forms. The forms were signed and dated by the client on January 15, 2014 for the client ' s family, funding source and laboratory.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director met with Quality Assurance Team on November 20, 2014 to review and discuss the requirement pertaining to obtainment of informed and voluntary consent from each client as well as documentation of the date in which the staff signature was obtained. The Program Director educated the QA team regarding the need to ensure obtainment of specific information to be released on consent forms as well as the date in which the staff member signed as witness for all consent forms. The Quality Assurance Team will review every chart on a week to week basis in order to ensure the proper completion of all consents. The Program Director will select a sampling of charts each week as well to review consents as a means of ensuring continued compliance. On December 10, 2014, Clinical Supervisor removed all consents, which did not reflect informed and/or voluntary consent for client records #3 and 6. |