INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25-26, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Fayette County Drug and Alcohol Commission 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 personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of three personnel records.
The findings include:
Eight personnel records were reviewed on June 25-26, 2014. Three personnel records were required to have documentation of the qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel record # 6.
Employee # 6 was hired as a case manager on April 1, 2013 and promoted to counselor on June 2, 2014. Employee # 6 has a Bachelor of Arts in Psychology; however, she does not have one year of clinical experience. Her documented experience was in case management and TSS work, both of which are non-clinical.
The findings were reviewed with the clinical supervisor, project and facility directors on June 26, 2014. No additional experience was presented for review.
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Plan of Correction
Effective immediately, FCDAC will ensure all future applicants applying for the position of Treatment Specialist meet the minimum qualifications set forth by 704.7 prior to hiring.
To ensure that FCDAC meets 704.7(b) Counselor Qualifications, effective immediately, FCDAC will change the employment status of employee #6 to Counselor Assistant. As a means to adequately supervise the counselor assistant, the Clinical Supervisor has developed a supervisory plan to meet the requirements set forth in 704.9(a)(b)(c). Counselor #6 meets the educational requirements set forth by 704.8 by possessing a Bachelor's Degree in the human service area and already meets the training requirements set forth by 704.11. Counselor #6 will receive supervision by the clinical supervisor and by the lead counselor to abide by the 704.9 regulations on a regular basis. This supervision will include; working the same schedule, co-signing progress notes and other related client documentation and random observations of clinical sessions. The clinical supervisor and lead counselor will document direct observations that include date conducted, length and manner of supervision. Counselor #6 will also receive a written semiannual and annual performance evaluation based upon measurable performance standards set forth by FCDAC.
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