INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 25-26, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Rehabilitations Services, Inc. were 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 personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of two personnel records.
The findings include:
Two personnel records which required documentation of the qualifications for the position of counselor were reviewed on September 23, 2013. The facility failed to provide documentation of counselor qualifications in personnel record # 7.
Employee # 7 was hired as a counselor assistant on 11/26/12 and was promoted to counselor on 5/26/13. Employee # 7 has a Bachelor of Arts in Psychology which meets the educational requirements; however, they did not have the required one year clinical experience prior to being promoted to counselor. Employee # 7 only had 6 months of clinical experience at the time of promotion to counselor.
The Project Director and Facility Director confirmed the findings.
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Plan of Correction
Employee #7, will be assigned the title of "Counselor Assistant" until they have completed the required 12 months of direct clinical experience in the field alcohol and drug addiction. The Counselor Assistant title will remain until 11/26/13. The project director/facility director will ensure that all future hires, prior to being promoted to the position of Counselor, will be scrutinized against the licensing standards to verify that previous clinical experience meets criteria for appropriate supervision as outlined in 704.7 (3). |
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 personnel and training records, the facility failed to provide documentation of TB/STD and HIV/AIDS training in two of four personnel records.
The findings include:
Four personnel records which required documentation of a minimum of four hours of TB/STD training and six hours of HIV/AIDS training were reviewed on September 23, 2013. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training within the first two years of employment.
Employee # 8 was hired as a youth care worker on 3/29/11. This employee was required to obtain four hours of TB/STD training and six hours of HIV/AIDS training by 3/29/13. Employee # 8 failed to obtain the training as of the date of the inspection.
Employee # 9 was hired as a youth care worker on 9/21/11. This employee was required to obtain four hours of TB/STD training and six hours of HIV/AIDS training by 9/21/13. Employee # 9 failed to obtain the training as of the date of the inspection.
The Project Director and Facility Director confirmed the findings.
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Plan of Correction
All DARS Inc. clinical staff will attend sponsored trainings on TB/STD, as well as HIV/AIDS within the first 12 months of employment with the agency. All other staff not employed in a clinical capacity will receive TB/STD and HIV/AIDS training within 24 months of employment with the agency. DARS, Inc. will utilize both external training opportunities and the approved curriculum to fulfill these training requirements. Certificates of completion will be filed in all employee training files with the agency. Employee #8 and employee #9 will attend the required trainings on 11/16/13. |