INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on November 7-9, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Drug and Alcohol Services of Beaver Valley 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 two of three personnel records.
The findings include:
On November 7, 2011 nine personnel records were reviewed. Three of the personnel records reviewed pertained to new counselors hired in the last licensing year. The facility failed to provide documentation of counselor qualifications in personnel records # 6 and 7.
Employee # 6 was hired as a counselor on October 17, 2011. Employee # 6 has a Bachelor of Sciences in Biobehavioral Health. This degree was found to meet the educational requirements; however, employee #6 does not have one year of clinical experience. Employee #6 did not have any clinical experience prior to being hired for this position.
Employee # 7 was hired as a counselor on February 8, 2011. Employee # 7 has a Bachelor of Science in Human Resources Management, which does not meet the educational requirements.
Interviews with the project/facility occurred at multiple times on November 7 & 8, 2011. The aforementioned information was confirmed and no additional information could be located to show additional education and/or experience for either of the counselors.
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Plan of Correction
Employee #6 has been designated as a Counselor Assistant. A full-time lead counselor will supervise employee #6. During this supervision period, employee #6 will complete the training requirements for staff development, receive coaching from his supervisor, and meet weekly with his supervisor to assess skill levels. All meetings and observations will be documented. Employee #6 will receive a written semiannual preformance evaluation based on measurable preformance standards before he can be promoted.
Employee #7 has been designated a counselor assistant. Employee #7 will work under the direct observation of the clinical supervisor. All meetings, trainings and observations will be documented and will include co-signing progress notes, and client records of services. Employee #7 has documented his intention to apply for his AAC in March 2012.
Both employee #6 and #7 will work with their supervisor. Supervisors will maintain records of the supervision provided. The executive director will monitor the training and progress to insure records are completed and all staff are meeting requirements.
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative materials, the project failed to complete the 2010 audit by the end of the project's fiscal year.
The findings include:
A review of administrative materials was conducted on November 7, 2011. The project's fiscal year is from July through June. The project failed to document the completion of an annual audit for the fiscal year ending June 30, 2010 by the end of the fiscal year. The audit for the fiscal year ending June 30, 2010 was completed on May 6, 2011.
On November 7, 2011 at approximately 2:45 PM, the project/facility director confirmed the completion date for the audit completed for the fiscal year ending June 30, 2010.
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Plan of Correction
This agency has obtained a new independent public accountant for the 2011 audit. The 2011 audit will be completed by December 31, 2011. Progress is being monitored by the Executive Director. |