INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 21, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mid-Atlantic Rehabilitation Services - A.T.P. 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 one of twenty employee personnel records reviewed, the facility failed to provide documentation of the qualifications of one counselor.
Employee # 11 was hired as a counselor on June 8, 2023, and was still in this position at the time of the inspection. Based on a review of employee # 11's personal record and resume, there was a qualifying bachelor ' s degree however there was no documentation of at least one year of clinical experience.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility interpreted Employee #11 prior and current work as clinical. Clinician currently meets position of counselor requirements with experience. Human Resources will review the clinical experience of all new hires prior to them beginning the position. If questions arise regarding 1 year of experience. Human resources will forward resume to DDAP licensing for assistance. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on three of eight applicable client records reviewed, the facility failed to provide documentation of an individual treatment and rehabilitation plan being developed with the client.
Client # 1 was admitted on April 6, 2023, and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan developed on July 6, 2023, did not include documentation of the plan being developed with the client.
Client # 3 was admitted on September 6, 2023, and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan developed on October 25, 2023, did not include documentation of the plan being developed with the client.
Client # 8 was admitted on May 23, 2023, and was discharged October 13, 2023. The comprehensive treatment and rehabilitation plan developed on June 23, 2023, did not include documentation of the plan being developed with the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An in-service will be held with clinicians by the quality assurance department by 2/1/24. Quality assurance will review all treatment plans for signatures and/or documentation in progress notes of clients participation in development of plan. This treatment plan audit will be conducted monthly. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on two of three applicable client records reviewed, the facility failed to provide an aftercare plan for clients not continuing in formal treatment as provided by the facility policy and procedure manual in client records # 9 and 10.
Client # 9 was admitted on January 6, 2023, and was discharged on July 7, 2023.
The aftercare plan was not completed in the client record.
Client # 10 was admitted on June 6, 2023, and was discharged on October 25, 2023.
There was no aftercare plan available in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Quality assurance department will conduct an in-service by 2/1/24 with clinicians addressing policy and procedure on completion of aftercare plans. Quality assurance will audit closed charts monthly to ensure completion of aftercare plans on those with successful discharges. |