INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 12, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Conewago Snyder 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 eight personnel records, the facility failed to document that one counselor met both the education and experiential qualifications for the position.
Employee #7, who was hired as a counselor on December 22, 2022 and was still in the position at the time of the inspection. At the time of hire employee #7 had a qualifying bachelor ' s degree but did not have the one year of clinical experience documented.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor received DDAP regulations regarding the counselor assistant requirements on 07/14/2023. These regulations were then reviewed in the Clinical Supervisor's monthly supervision with Corporate Clinical Director to clarify expectations and requirements for the supervision of counselor assistants. Staff who are identified as counselor assistants will be supervised weekly by a full-time supervisor or counselor for the required length of time based on the counselor assistant's degree. A counselor assistant with a Master's degree will receive 3 months of weekly close supervision, a counselor assistant with a Bachelor's degree will receive 6 months of weekly close supervision, and a counselor assistant with an Associate's degree will receive 9 months of weekly close supervision. Close supervision will align with DDAP regulations regarding weekly direct observation and weekly case review. Supervision notes will document a weekly case review which includes client initials or identifying number and an hour of direct observation. The hour of direct observation will then be referenced in the chart of the client with whom it is conducted. The Clinical Supervisor completing the clinical supervision sheet will observe and document the counselor assistant's interaction and intervention with the client(s), noting counselor performance and effectiveness, utilizing stated criteria specified on supervision sheets. The Clinical Supervision Sheet has been updated to present these requirements with more clarity. Supervision sessions will review the counselor assistant's clinical skills, strengths, and areas for improvement. Counselor assistants currently employed will start following this protocol immediately. The Clinical Supervisor will forward counselor assistant supervision sheets, fully completed with signatures, to the Corporate Clinical Director and the Facility Director by end of business day each Friday to ensure compliance with these regulations. The Corporate Clinical Director will review the supervision sheets to ensure compliance with the regulations and to ensure that supervision is happening as appropriate. The Corporate Clinical Director, Facility Director, and Clinical Supervisor will meet between 10/23/2023 and 10/27/2023 to determine if these will continue to be received on a weekly basis, or if the supervision sheets can be received once monthly moving forward. Signed supervision sheets for counselors will be submitted to the Corporate Clinical Director and Facility Director by the last Friday of the month.
As of 8/22/23, Employee #7 will have a one year of clinical experience documented, 4 months achieved prior to employment with Firetree, and 8 months employed with Firetree as a clinician. Employee #7 received weekly supervisions for the first months of her employment. These supervisions are documented and present in Employee's HR file. Employee #7 had a positive performance evaluation completed on 05/25/23. Future candidate's for clinical positions qualifications will be screened and approved by the Corporate Clinical Director using the DDAP regulations for staffing requirements effective immediately. |
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 eight personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #6 was hired as a counselor assistant on December 6, 2021 and then promoted to a counselor on April 2, 2023 and was due to have the communicable disease trainings no later than December 6, 2022. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee has been registered for the following course:
TB/STD/Hepatitis (4 hour) (VIRTUAL TRAINING)
Victoria Lahey
Course Date: Oct 17 2023 to Oct 17 2023.
Course Time: 9:00 AM to 1:00 PM
Course Location: Virtual - Host: Allegheny County
Virtual
Virtual, pa 15222
Director and clinical supervisors will continue to keep track of required trainings on the Master Staff spreadsheet. Verbal notifications of needed trainings will be given to staff during supervisions as well as assistance in locating and signing up for the trainings if needed.
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the large group counseling rooms located in the halfway house, women and men ' s wings.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Legal Counsel, George Bishop, and Corporate Compliance Officer will draft and submit a request for an exception from DDAP to have cameras in group rooms in the male, female and HWH wings of the facility. This request for an exception will be submitted by 8/1/23.
In the event that the exception is denied, all cameras in group rooms of male, female and HWH will be disabled and removed immediately upon reception of a denial. On site maintenance professional, can begin removing them the day we are denied. |