INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pittsburgh Organization for Women in Early Recovery (POWER) 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 staff records, the facility failed to document that each staff member providing clinical services met the qualifications of counselor in one of three records.
Staff #4 was hired as an intake staff on August 24, 2020 and promoted to counselor on April 10, 2023. Staff #4 ' s verified degrees do not meet the requirements of counselor as outlined by the Department.
This was reviewed with the facility staff during the licensing process.
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Plan of Correction
Staff #4 has been supervised weekly per counselor assistant requirements. Clinical Supervisor will continue to provide weekly supervision and document progress. Staff #4 will remain at counselor assistant status until qualifications can be re-reviewed at next inspection. Full transcripts have been received and are now available for review. In addition, staff #4 is currently enrolled in master's program.
Moving forward, the facility will not count time spent in assessment only roles as clinical experience. In addition, employment candidates will be required to submit full transcripts, including any transfer credits, so that proper determination may be made as to whether a person needs to start in a counselor assistant role prior to moving to counselor once qualified. This process will be monitored by the Facility Director. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in one of seven staff records.
Staff #7 was hired as a residential support staff member on June 1, 2021. The TB/STD training was to be completed by June 1, 2023. There was no documentation that this training was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Met with Residential Support Staff Supervisor in supervision on 7/25/2023 and reviewed the timeframe of required DDAP training for HIV/AIDS and TB/STD training. Developed a training tracker for all RSS employees for RSS Supervisor to use to ensure timelines are adhered to for all DDAP trainings. All RSS staff will have HIV/AIDS and TB/STD training completed within 2 years of hire. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of staff records, the facility failed to provide documentation of at least 25 clock hours of annual training required for a counselor for the training year July 2022-June 2023 in one of three records.
Staff #5 was hired as a counselor on April 11, 2022 and was still in this position at the time of the inspection. During the review of the staff record, 17.5 training hours were able to be verified.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will monitor training hours for all counselor staff to ensure that required hours are met. Changed the practice of Executive Administrative Assistant tracking hours to the Direct Staff supervisor. Supervisors will monitor each staff in supervision to track training hours during the training year. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the facility's fire drill log for the months of October 2022 through June 2023, the facility failed to utilize alternating exits during monthly fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Conducting fire drills and completing the logs are the responsibility of the Office Manager. Office Manager was retrained by Facility Director in supervision on 7/24/2023 to ensure that we are using alternated exit routes each month. Fire Drill logs will be turned in to Facility Director one week prior to the end of each month to ensure that a proper drill has been conducted and to allow one week timeframe to run another drill if the Facility Director finds any issues with the log that was submitted. The Facility Director is responsible for ensuring that this new plan is implemented. |
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
Based on a review of staff records, the facility failed to provide documentation of an annual written individual staff performance evaluation reviewed for one of one staff reviewed.
Staff #1 was hired as the project director on September 1, 1992 and still in this position at the time of the inspection. During review of staff record, an annual written individual staff performance evaluation was not provided at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Board of Directors did not complete an annual evaluation for the Project Director within the appropriate timeframe and it was not complete at the time of the licensing inspection. This was an oversight by the Project Director and the Board and it is understood that this evaluation needs to happen on a yearly basis. The performance evaluation is currently being completed by the Board and can be sent to DDAP by completion date if needed. Moving forward, the annual evaluation for Project Director will happen on a yearly basis as required |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of medication storage area inspection logs, the facility failed to conduct quarterly inspections per facility policy. During the inspection, only one inspection was documented on June 9, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing staff notified pharmacy and the Lead Pharmacist will provide monthly inspections the first week of every month moving forward starting with August. This will ensure we meet the quarterly inspections requirements. The Facility Director is responsible for ensuring this plan is followed. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in two of four records. The policy and procedure manual indicates follow-up contact must be made within seven days after discharge.
Client #1 was admitted to detox on June 26, 2023 and was discharged on June 26, 2023. Follow-up contact was due to be completed no later than July 2, 2023, however, this was not completed at the time of the inspection.
Client #7 was admitted to detox on February 15, 2023 and was discharged on February 18, 2023. Follow-up contact was due to be completed no later than February 25, 2023, however, this was not completed until February 27, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director retrained clinical staff during clinical team meeting on 7/19/2023 of necessity to complete the follow up contact within 7 days of discharge. Clinical staff were instructed to schedule the call prior to the 7th day to avoid occurring on a day that counselor does not work and to allow time to reschedule if needed. The Clinical Supervisor is responsible for ensuring this plan is followed and will monitor with regular chart audits. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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
Based on applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in four of seven records. The facility policy and procedure manual indicate a case consultation to occur every fourteen days.
Client #10 was admitted to inpatient on April 21, 2023 and discharged on May 19, 2023. A case consultation was due to occur no later than May 4, 2023, however this was not completed until May 12, 2023.
Client #11 was admitted to inpatient on April 3, 2023 and discharged May 6, 2023. A case consultation was due to occur no later than May 1, 2023, however this was not completed at the time of the inspection.
Client #13 was admitted to inpatient on June 6, 2023 and still active at the time of the inspection. A case consultation was due to occur no later than June 28, 2023, however this was not completed at the time of the inspection.
Client #14 was admitted to inpatient on June 6, 2023 and still active at the time of the inspection. A case consultation was to occur no later than June 20, 2023, however this was not completed until June 28, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director retrained clinical staff during clinical team meeting on 7/19/2023 of necessity to complete the case consults every 14 days. Clinical team meets every Wednesday and completes consultations for clients. These consultations will be documented in the electronic health record by the primary Counselor every 14 days. The Clinical Supervisor is responsible for ensuring this plan is followed and will monitor with regular chart audits. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in three of four records. The policy and procedure manual indicates follow-up contact must be made within seven days after discharge.
Client #9 was admitted to inpatient on April 27, 2023 and was discharged on May 25, 2023. Follow-up contact was due to be completed no later than June 1, 2023, however, this was not completed until June 8, 2023.
Client #10 was admitted to inpatient on April 21, 2023 and was discharged on May 19, 2023. Follow-up contact was due to be completed no later than May 26, 2023, however, this was not completed at the time of the inspection.
Client #11 was admitted to inpatient on April 3, 2023 and discharged May 6, 2023. Follow-up contact was due to be completed no later than May 13, 2023, however, this was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director retrained clinical staff during clinical team meeting on 7/19/2023 of necessity to complete the follow up contact within 7 days of discharge. Clinical staff were instructed to schedule the call prior to the 7th day to avoid occurring on a day that counselor does not work and to allow time to reschedule if needed. The Clinical Supervisor is responsible for ensuring this plan is followed and will monitor with regular chart audits. |