INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 11, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Salvation Army Harbor Light 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 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
The facility failed to document that each counselor met the educational and experiential qualifications for the position.
Four counselor records were reviewed on May 11, 2018. Two of the counselors reviewed did not meet the experiential requirements for the position.
Staff #6 was hired on 2/6/17 to complete client intakes. On 9/15/17, she was placed into the counselor position. Staff #6 holds a Bachelor Degree in Psychology; however, she does not have the one year of clinical experience required for the position.
Staff #7 was hired on 7/22/16 as a tech. On 12/19/17, he was placed into the counselor position. Staff #7 holds a Associates Degree in Social Work; however, he does not have the two years of clinical experience required for the position.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff #6 & Staff #7 will receive monthly, documented supervision as a counselor assistant until they qualify to be a counselor.
Staff #6 will acquire 4 months of supervision which will take her to September 2018. - clinical supervisor will complete the monthly supervision and keep documentation.
Staff #7 will acquire 8 months of documented supervision as a counselor assistant. This will give him the one year of experience because in May 2018 he received his bachelors degree in social work. - clinical supervisor will schedule and document monthly supervision.
Moving forward, the director of the program will be assess necessary qualifications of counselors and counselor assistance as part of the initial job screening process and make hiring decisions based on these DDAP requirements of those positions. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
The project/facility director failed to complete at least 12 hours of training for the 2017 training year.
Staff training was reviewed on May 11, 2018. The facility's training year runs from January - December and 2017 was reviewed during this inspection. For the 2017 training year, Staff #1 had 6 hours of training documented for 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director will be more cognizant of the annual training requirements moving forward and schedule and attend at least the 12 hours per year required of this position. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
As of the date of the inspection, May 11, 2018, the facility failed to document an annual financial audit completed by an independent certified public accountant for the 2016-2017 fiscal year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Within the next 6 months, the director of the program will schedule an outside auditor to complete a financial audit for the Harbor Light Centers 2016-2017 fiscal year. This annual audit will continue through this and future fiscal years. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to notify clients, in writing, of the decision to involuntarily terminate the client's treatment at the project.
Seven client records were reviewed on May 11, 2018. Three of the clients reviewed were involuntarily terminated from treatment. Client #5 was terminated from treatment on April 20, 2018, client #6 was terminated from treatment on April 27, 2018 and client #7 was terminated from treatment on February 24, 2018. Client records #5, 6 and 7 did not include documentation of written notification of involuntary termination.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward, the director of the Harbor Light program will develop a letter to give to clients when there is a decision to involuntarily terminate the client. The letter will include reason for termination and the appeal process if the clients want to appeal the decision. The director will be responsible for this. |