INITIAL COMMENTS
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Graff, TinaThis report is a result of a supervisory review of the written report of the findings of an on-site licensure inspection that was conducted on February 19, 2015, by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from the on-site inspection, Crossroads Counseling 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 supervisory review:
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the "Staffing Requirements Facility Summary Reports" (SRFSR) for all of the facilities in the Project, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the Project.The findings include:A review of the SRFSR was conducted on May 15, 2015. The SRFSR for the four facilities that make up the project list a total of 25 counselors, 3 counselor assistants, and 4 clinical supervisors. The total of the hours per week provided to the project by counselors equates to 27.425 FTE counselor positions within the project, thus, requiring 3 full time clinical supervisors.The SRFSR for the four facilities within the project listed four employees as clinical supervisors, two as full time clinical supervisors and two that also served in the capacity of clinicians. Therefore, two of the clinical supervisors were unable to provide full-time clinical supervision.
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Plan of Correction
Executive Director will complete the facility staffing form and properly document the number of clinical hours under the correct headings. ED now understands that when completing the clinical staffing form that clinical supervisor time is to be assigned to the "other" category rather than being assigned to "drug and alcohol." The executive director will be also responsible for completion and review of the Staffing Requirements Facility Summary Report prior to pre-submission and be responsible to ensure that the agency always meets the requirements of 704.6(a). We currently have 4 full time clinical supervisors. |
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 the Staffing Requirements Facility Summary Report, the facility failed to ensure that each counselor met the qualifications for the position. The findings include:The Staffing Requirements Facility Summary Report and supplemental documentation were reviewed on May 15, 2015. The facility failed to ensure that employee #4 met the educational requirements for the position of counselor. Employee # 4 was hired as a master's level counselor on 12/18/2014 . Employee #4 did not meet the qualifications for the position of counselor as they did not have a master's degree with an approved major. Employee # 4 received a Master of Education degree with a concentration in American History.
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Plan of Correction
We are aware of the staffing requirements and intend to fully comply with them. The staff member in question is no longer with our organization. The project director will review and approve all new hires prior to them beginning any clinical work to ensure that each individual hired meets the counselor requirements as identified in 704.7(b).
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