INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 30, 2006 to August 31, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on September 26, 2006.
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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
Employee number 5, listed as counselor, had allowed his CAC and CCDP credentials to lapse. This employee's Bachelor's degree is in General Studies/English which does not appear to meet the human service related requirements. Therefore, since the staff does not have a current CAC or CCDP, he does not meet the qualifications for counselor.
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Plan of Correction
Employee number 5 was suspended from his duties until he completed the required trainings and his CAC was validated. He returned to work on 9/18/06 with a current CAC. To avoid future occurrences the facility director will maintain employee training files separate from the files kept by the human resource office for each employee. These files will include copies of all employee's current certifications and licenses and trainings that have been completed for the current fiscal year and for the previous year if applicable toward certification or licensure. The facility director will be responsible for a quarterly review of these files. There will be a signature sheet attached to the front inside cover of each file which will be signed and dated upon completion of each review. In addition, the signature sheet will contain a synopsis of the requirements that an individual must meet to maintain his or her employment in accordance with Department of Health regulations/ Bureau of Drug and Alcohol Programs.Employee training files will be completed by 9/29/06.
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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
There was no documentation of the six month probationary evaluation or of the annual performance evaluation for employee number 4, a counselor assistant.
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Plan of Correction
The yearly evaluation was completed on employee number 4 on 9/6/06. To prevent another occurrence of missed evaluations the individual personal training file generated by the facility director (referenced in POC #:0037) will contain information regarding the required frequency of the employee's evaluations. This file will be reviewed every three months, however in an effort to have all reviews occur on a quarterly basis in line with our fiscal year the new employee's file review may occur more frequently to bring it in line with the standard time line for review. The facility director's signature on the review sheet indicates that he or she has read the synopsis of that employee's requirements and updated the file accordingly. The facility director is responsible for all performance evaluations.
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Out of 9 employee records reviewed, record numbers 1, 2, 4, 5, 6, 7, 8, and 9 did not have a training needs assessment completed for the 2006-2007 training year. Evidence of this assessment could include questionnaires completed by all staff with data compiled, or a narrative summarizing group discussion of needs.
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Plan of Correction
All employees completed a training needs questionnaire. Summaries of employee needs will be completed by the facility director and placed in their individual training files by 9/29/06. Employees will provide evaluations of the various trainings they attend throughout the year for further evaluation of training needs.
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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Out of 9 employee records reviewed, record numbers 1, 2, 4, 5, 6, 7, 8, and 9 did not have a training plan completed for the 2006-2007 training year. This individual plan is to be based on the assessment of staff training needs which should address training subjects, trainers, and proposed dates of training.
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Plan of Correction
All employees completed a training needs questionnaire on or prior to 9/29/06 and a summary of their needs was placed in their individual training file on 9/29/06. All employees that do not have a current CPR certification will have CPR training on 11/20/06. This is a four hour training and the instructor is Dawn Warren. Corporate Compliance I & II refresher training will be held for all employees on 11/27/06. This is also a four hour training and the instructor is Angela Narehood. The CPR training will be held at the Shamokin Outpatient Office and Corporate Compliance training will be conducted at the Sunbury office. In addition, all staff will be attending the HIV/AIDS Clinical Update training that is being hosted by PA Department of Health on 12/14/06 at the Genetti Hotel and Conference Center in Wilkes-Barre, PA. The employees will obtain 6.5 credit hours for this training. The one employee exception for the HIV/AIDS training is employee # 6, who will receive this training through his other employer. All employees have been provided with brochures listing various trainings being offered throughout PA.
Employee #1 is a counselor assistant and will therefore be required to complete 40 hours of training by June 30th, 2007. This employee has expressed interest in the following trainings: Cognitive Behavioral Therapy, Forensic Training, Dual Diagnosis Training, Juvenile Sex Offenders, and PTSD training.
The following trainings have been presented to employee #1 for consideration: Dialectical Behavioral Therapy training is being offered on December 6th and 7th at the Elks Lodge in Danville PA. This 10 hour course is sponsored by Drexel University; Forensic Prerequisites, being offered on January 16 at the Elks Lodge in Danville PA. This 6 hour course is sponsored by Drexel University; PTSD: Posttraumatic Effects Throughout the Lifespan, this training is being offered on November 7th and 8th at the Elks Lodge in Danville PA. This 10 hour course is sponsored by Drexel University; Juvenile Sex Offending: Development, Treatment, and Correction, this training is being offered on January 17th 2007 at the Elks Lodge in Danville, PA and is sponsored by Drexel University. Overview of Substance Abuse, This training was suggested by the facility director. It is a PCB approved training being offered on November 8th and 9th at the Comfort Inn, Harrisburg and it is approved for 12 PCB credits. The presenter is Darren Skinner, CAC/CCDP Diplomat.
Employee #2 is a counselor assistant, however, she is eligible for promotion to a counselor position. Employee #2 works closely with employee #1 and she presented the same training interests with the exception of the sex offender training because she had recently completed this training. All the other trainings that were presented to employee #1 were also presented to employee #2.
Employee #3 is a D&A counselor and an LSW and is required to complete 25 hours of training by June 30th, 2007. This employee has expressed interest in the following trainings: Chronic Pain and Addiction, Codependency, Dealing with Resistant Clients, Personality Disorders especially co-occurring Borderline Personality Disorder and addiction.
The following trainings have been presented to employee #3 for consideration: Motivational Interviewing in Substance Abuse Counseling ? Meeting Clients Where They Are, (this training may be beneficial in dealing with resistant clients). This training is being offered on November 17, 2006 at the Comfort Inn, Harrisburg and is PCB approved for 6 credit hours. There are no other trainings currently available for employee #3's areas of interest. She has been provided with a list of available trainings and she will be provided with information on trainings that become available in the future.
Employee #4 has resigned her position.
Employee #5 is a D&A Counselor and he has a CAC. He is required to complete 25 credit hours of training by June 30th, 2007. He expressed interest in the following areas of training: Co-occurring Disorders, Relapse Prevention, Treating Substance Abuse as Opposed to Addiction (juvenile) and Cognitive Behavioral Therapy.
The following trainings have been presented to employee #5 for consideration: Dialectical Behavior Therapy training is being offered on December 6th and 7th at the Elks Lodge in Danville PA. This 10 hour course is sponsored by Drexel University; Motivational Interviewing in Substance Abuse Counseling ? Meeting Clients Where They Are, (this training may be beneficial in dealing with clients that have abuse issues rather than addiction problems). This training is being offered on November 17, 2006 at the Comfort Inn, Harrisburg and is PCB approved for 6 credit hours. The trainer is Sherly Laffey, CAC. There are no other trainings currently available for employee #5's areas of interest. He has been provided with a list of available trainings and he will be provided with information on trainings that become available in the future.
Employee #6 is a D&A Counselor with a CAC. He is required to complete 25 credit hours of training by June 30th, 2007. Employee #6 expressed interest in the following trainings: Cultural Awareness, Co-occurring Disorders, Treatment for incarcerated clients.
The following trainings have been presented to employee #6 for consideration: Cultural Competence: Steps and Skills in a Recovery-Oriented System, This training is being offered on November 10th, 2006 at the Holiday Inn Harrisburg/Hershey, Grantville, PA. This 6 hour course is sponsored by Drexel University; Addicted Criminal Offender: Commonalities of Criminal Personality and Substance-Related Disorders. This 6 hour PCB approved training is being offered on November 17, 2006 at Eagleville Hospital, Eagleville, PA. The presenter is Dean Bowman, CAC/CCJP/CCDP. There are no other trainings currently available for employee #6's areas of interest. He has been provided with a list of available trainings and he will be provided with information on trainings that become available in the future.
Employee #7 is a Fee For Service Masters' Level D&A Counselor and she is required to complete 25 credit hours of training by June 30th, 2007. Employee #7 expressed interest in the following trainings: Anxiety Disorders and Addiction, Multicultural Counseling, Spirituality in Recovery and Relapse Prevention Techniques.
The following trainings have been presented to employee #7 for consideration: Anxiety Disorders Research, Diagnosis and Treatment. This 6 hour training is being offered on November 14th, 2006 at the Crown Plaza Harrisburg and is sponsored by Cross Country Education. The presenter is Wayne Eastlack, Ph.D.; Cultural Competence: Steps and Skills in a Recovery-Oriented System, This training is being offered on November 10th, 2006 at the Holiday Inn Harrisburg/Hershey, Grantville, PA. This 6 hour course is sponsored by Drexel University; Spiritual Nature of Addiction Treatment. This 6 hour PCB approved training is being held on November 3rd , 2006 at Eagleville Hospital, Eagleville, PA. The presenter is Steven Safko, CAC. There are no Relapse Prevention trainings currently available but employee #7 has been provided with brochures listing various trainings being offered throughout PA.
Employee #8 is the Facility Director and he is required to complete 12 credit hours of training by June 30th, 2007. He will be attending the HIV/AIDS training with the other counselors and has expressed interest in clinical supervision training, treatment of Anxiety Disorders and Motivational Interviewing and Treating Criminal Offenders.
The following trains are being considered: Basics of Clinical Supervision. This is a 6 hour PCB approved training being offered on December 1st, 2006 at Gateway Greentree, Pittsburgh, PA. The presenter is John Massella, CCS/CCDP Diplomat; Anxiety Disorders Research, Diagnosis and Treatment. This 6 hour training is being offered on November 14th, 2006 at the Crown Plaza Harrisburg and is sponsored by Cross Country Education. The presenter is Wayne Eastlack, Ph.D.; Motivational Interviewing in Substance Abuse Counseling ? Meeting Clients Where They Are, This training is being offered on November 17, 2006 at the Comfort Inn, Harrisburg and is PCB approved for 6 credit hours. The trainer is Sherly Laffey, CAC; Addicted Criminal Offender: Commonalities of Criminal Personality and Substance-Related Disorders. This 6 hour PCB approved training is being offered on November 17, 2006 at Eagleville Hospital, Eagleville, PA. The presenter is Dean Bowman, CAC/CCJP/CCDP.
Employee #9 is the Office Manager and does not provide treatment to any clients. She was required to attend the initial new hire trainings and HIV/AIDS training. She has expressed interest in attending the following trainings: Basics of Addiction and Confidentiality.
The following trainings have been presented to employee #9 for consideration: Overview of Substance Abuse, This is a PCB approved training being offered on November 8th and 9th at the Comfort Inn, Harrisburg and it is approved for 12 PCB credits. The presenter is Darren Skinner, CAC/CCDP Diplomat; Ethics for Drug and Alcohol Professionals. This is a 6 hour PCB approved training being offered on November 13, 2006 at Gateway Rehabilitation Center, Aliquippa, PA. The presenter is Frank Jans. Employee #9 has been provided with brochures listing various trainings being offered throughout PA.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Fire extinguisher training was not documented for new employees numbers 1, 2, 4, 5, 6, and 7. Instruction may be included in the employee orientation, but must occur no later than seven days from the date of employment.
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Plan of Correction
Fire extinguisher training was completed by employees numbers 1, 2, 4, 5, 6, and 7 on 9/15/06. The training was conducted by Richard Pawlicki, who is the Captain of a local volunteer fire company.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Emergency training training was not documented for new employees, numbers 1, 2, 4, 5, 6, and 7. This training, as with the fire extinguisher training, may be included in the employee orientation, but must occur no later than seven days from the date of employment.
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Plan of Correction
Emergency training was conducted on 9/18/06 for all employees that had not received this training. It will be conducted during the first week of employment preferably during their first day on site (i.e., which is usually their second day of employment). The requirement for this training will be documented in the synopsis in the individual's training file that will be generated and maintained by the facility director. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Performance evaluations were not completed as per agency policy for employee numbers 4, 5, 6, 7, 8, and 9.
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Plan of Correction
The frequency of required performance evaluations will be documented in the synopsis of the employee's individual training file. This file will be reviewed quarterly by the facility director. All evaluations have been completed as of 9/20/06. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Out of 7 client records reviewed, client record numbers 1 and 2 did not have a preliminary treatment plan.
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Plan of Correction
Treatment planning and Case Consult training was conducted on 9/18/06 by the facility director. In addition, our psychiatrist will be at our Academy site every Thursday and he will review new preliminary and master treatment plans and treatment plan updates at that time. In the past some treatment plans were frequently being mailed to him which caused a delay in the approval process. Preliminary treatment plans have been completed for record numbers 1 and 2 as of 9/20/06. |
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
Out of 7 client records reviewed, client record numbers 1 and 3 did not have comprehensive treatment plans.
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Plan of Correction
Treatment planning and Case Consult training was conducted on 9/18/06 by the facility director. In addition, our psychiatrist will be at our Academy site every Thursday and he will review new preliminary and master treatment plans and treatment plan updates at that time. In the past some treatment plans were frequently being mailed to him which caused a delay in the approval process. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Out of 7 client records reviewed, client record numbers 1, 3, and 4 did not have treatment plan updates.
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Plan of Correction
Treatment planning and Case Consult training was conducted on 9/18/06 by the facility director. In addition, our psychiatrist will be at our Academy site every Thursday and he will review new preliminary and master treatment plans and treatment plan updates at that time. In the past some treatment plans were frequently being mailed to him which caused a delay in the approval process. Client record numbers 1, 3, and 4 have been completed with treatment plan updates. Some of our counselors had been writing new treatment plans rather than using updates. |
709.93(a) 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:
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Observations
Out of 7 client records reviewed, client record numbers 1, 3, and 4 were incomplete as they did not consistently include treatment plans, treatment plan updates, and case consults.
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Plan of Correction
Treatment planning and Case Consult training was conducted on 9/18/06 by the facility director. In addition, our psychiatrist will be at our Academy site every Thursday and he will review new preliminary and master treatment plans and treatment plan updates at that time. In the past some treatment plans were frequently being mailed to him which caused a delay in the approval process. Client record numbers 1, 3 and 4 have been completed with treatment plan updates and case consults as of 9/20/06. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Out of 7 client records reviewed, client record numbers 1, 3, and 4 did not document case consults. Each client's progress should be reviewed at least quarterly at a case conference consisting of representatives from the various client service components. Where a multi-disciplinary staff does not exist, case consultation should include the primary counselor and one other clinician.
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Plan of Correction
Treatment planning and Case Consult training was conducted on 9/18/06 by the facility director. All staff were in attendance. In addition, random charts will be pulled and reviewed monthly to ensure that case consults are being conducted and documented correctly. Client record numbers 1, 3 and 4 have been completed with treatment plan updates and case consults as of 9/20/06.
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