INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 24-26, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Impact Counseling Services LLC 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 hire a staff person who meets the qualifications of counselor.
Staff # 4 was hired as a counselor on January 2, 2018. At the time of hire, she did not meet the one year of experience requirement for the counselor position.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
a. The Facility Director of Impact Counseling Services, LLC will make the following changes to ensure full compliance of qualifications for new hires. The Facility Director, has developed a "New Hire" form for all new staff hired for our agency. This form will identify each new hires credentials, education and experience required for designated positions. The form will document review of information by agency directors or designee.
b. Degrees and transcripts required for positions will be reviewed by the Project and Facility Directors to ensure qualifications meet state regulations. This will include ensuring the degree is from an accredited college. Additional attention will be placed on experience in the field of drug and alcohol prior to hire. Should any questions arise regarded the designated degree, credentials or required experience, the Directors will contact the Department of Drug and Alcohol Programs to secure approval of the requirements for the designated position.
c. The Facility Director, will ensure candidates for counselor position have completed the one year experience requirement for this position. Candidates will be required to provide written documentation of where the experience occurred, their role in that program and the specific drug and alcohol clinical experience during that year. This documentation will be filed in their employee chart.
d. The "New Hire" form will be completed by agency directors or designee on all new hire candidates ensuring requirements and qualifications were reviewed and met. Documentation will be singed off on the new hire form by the directors and/or designee. Any contact or approval by the Department of Drug and Alcohol Programs relating to a new hire will be logged on this form as well.
e. All staff hires for Impact Counseling will be determined by the Project Director and Facility Directors to ensure full compliance of all qualifications for designated positions are met.
f. "New Hire" forms will be completed on all new hires at Impact Counseling Services, LLC beginning 10/15/19. These forms will be mandated and placed in all new hire employee charts.
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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
The facility failed to document employees were trained in the use of fire extinguishers upon hire in two personnel records, #5, #6.
Staff #5 was hired March 19, 2018, and training was not documented until September 10, 2019.
Staff #6 was hired March 19, 2018, and training was not documented until September 7, 2018.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
The Facility Director of Impact Counseling Services, LLC has made the following changes to ensure compliance with fire safety and fire extinguishers training for all new hires with our agency.
A "New Hire" form has been developed by The Facility Director to include all necessary new hire requirements. This check list will be completed upon all new hires first day of employment by the Agency Directors or designee. The form will include completion of required fire safety / fire extinguisher trainings and will also include signed documentation of the trainings by the new hire. This form will be placed in the new hires employee chart and will be reviewed and signed by the Facility Director or agency designee to ensure completion of all requirements on the hew hires first day of employment with Impact Counseling Services, LLC.
This will begin effective immediately on 10/22/19 and will be monitored by the Facility Director |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The facility failed to document the employee signed the annual performance evaluation in personnel records #3, 4, 5, 6, and 11 which were reviewed on September 24-25, 2019.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
The Facility Director with Impact Counseling Services, LLC will make necessary changes to all staff/personnel evaluation forms to include required space for employee signature and date of evaluation. This added change has been made to our evaluations and will require staff/employee signature for completion of form. The form will then be placed in the employee chart by the Program and Facility Director.
The change to this form is effective immediately. No employee evaluation form will be placed into the designated employee chart without required signatures of director and staff.
This will begin effectively immediately on 10/22/19
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709.93(a)(3) 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:
(3) Record of services provided.
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Observations
The facility failed to document a complete record of service in three of seven client records reviewed on September 25, 2019.
Client #5 had documentation of individual progress notes on June 14, 2019, July 16, 2019, July 26, 2019, and August 20, 2019 that were not documented on the record of service.
Client #6 had documentation of individual progress notes on August 26, 2019, and September 9, 2019 that were not documented on the record of service.
Client #7 had documentation of individual progress notes on August 29, 2019, and September 10, 2019 that were not documented on the record of service.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
The Facility Director at Impact Counseling Services, LLC will ensure completion of Record of Service Plans in all client files upon filing of progress notes/billing forms each week. The client Record of Service form will be located on the left side of all client charts and will be updated by the on sight administrative secretary when filing the forms.
Clinical supervisors assigned at each office will also complete random chart audits throughout the month to ensure that the Record Of Service Forms are up to date and match the progress note/billing forms of clients.
Any issues identified during the random chart audits in regard to Record of Service Forms will immediately be addressed with administrative staff to resolve any issues.
The Facility Director at Impact Counseling Services, LLC will also review random chart audits with staff and administrative personnel during monthly staff/clinical meetings. Any issues with specific concern to Record of Service will also be addressed at this time.
This process of filing and documentation of Record of Service forms will begin effective immediately (10/15/19). Supervisors will begin random chart audits beginning November 1, 2019 and will review in staff/clinical supervision during Novembers meeting.
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