INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection conducted on February 15, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Fayette Treatment Center, LLC d/b/a Greene Treatment Center 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 the 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
The facility failed to ensure that each counselor met the qualification for the position in one of three personnel records reviewed on February 15, 2017.
In personnel record # 3, the counselor did not meet the qualifications for the position of counselor as the employee's resume documented less than 1 year of clinical experience.
These finding were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On February 15, 2017, Greene Treatment Center failed to meet compliance for counselor qualifications in one of three counselor personnel records reviewed. Personnel record #3, which belonged to an employee who's resume documented work history with less than 1 year of clinical experience. Since the employee with personnel record #3 reviewed on February 15, 2017, did not meet the clinical experience required for counselors, the employee will be reassigned to the position of counselor assistant by the Project Director. At which time, the employee will follow a written training plan monitored by the Clinical Supervisor to specifically address achievement towards counseling competency in chemical dependency issues. If/when the employee has successfully reached documented counseling competencies in chemical dependency issues by completing established written training plan, the employee may be considered for a counseling position.
A Greene Treatment Center Facility Director or Clinical Supervisor will screen all potential applicants inquiring about counseling positions by first reviewing the applicants official educational transcripts to ensure compliance with PA Regulations 704.7, Staffing Requirements for Drug and Alcohol Treatment Activities; and then reviewing applicants documented work experience (resume/CV) to ensure applicants meet the clinical experience required in PA Regulations 704.7, Staffing Requirements for Drug and Alcohol Treatment Activities before interviewing potential applicants for Counselor positions.
This plan of correction will be implemented immediately, and by following this plan of correction Greene Treatment Center will be in compliance by April 23, 2017.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to document fire drills that included all components required for the fire drill logs reviewed on February 15, 2016.
The fire drill logs were reviewed for June 2016 to January 2017. The facility documented only the date of the fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During a review on February 15, 2017, Greene Treatment Center failed to meet compliance for not properly documenting fire drill requirements & execution of fire drills for June 2016 - January 2017, per PA DDAP Code 705.28(d) (no documentation of alarm or smoke detector operation during fire drills, no documented exit routes used, and improperly documenting the number of persons in the facility).
Per PA DDAP Code 705.28(d), Greene Treatment Center Project Director or designee will conduct unannounced fire drills at least once a month during normal staffing conditions to ensure all personnel on all shifts are trained to perform assigned tasks during emergencies. Greene Treatment Center Project Director or designee will maintain a written fire drill record for each fire drill including date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered, and whether the fire alarm or smoke detector was operative. Greene Treatment Center Project Director or designee will prepare alternate exit routes to be used during fire drills, conduct fire drills on different days of the week, at different times of the day and on different shifts, and set off a fire alarm or smoke detector during each drill. Prohibiting use of elevators during fire drills is not applicable because Greene Treatment Center facility is all one level.
This plan of correction will be implemented immediately by Greene Treatment Center Project Director, and by following this plan of correction Greene Treatment Center will be in compliance by April 23, 2017.
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