INITIAL COMMENTS
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This report is a result of a supervisory review of the written report from the findings of an on-site licensure inspection that was conducted on May 14, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from the on-site inspection, Gaudenzia Inc. Winner Co-Occurring Women and Children Program 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 supervisory review:
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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 the review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of two records reviewed.
The findings include:
Two personnel records were reviewed on May 14, 2015.
Personnel record #2 contained a signed job description for the position of counselor. Employee #2 has a Masters of Education with a major of Special Education with no clinical experience or documentation of a practicum.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia Winner Program Director will submit documentation to the Department that the counselor in question does meet the qualifications in both degree experience. Documentation will be submitted by 08/19/2015.
If it is determined by the department that the counselor in question does not meet the qualifications for a full time counselor than the Program Director will change the counselor's position to a counselor assistant III until full qualifications can be met. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of current client census information, the Staffing Requirements Facility Summary Report, and clinical staff hours the facility failed to ensure that the staff to client ratio remained at or below one full time equivalent (FTE) counselor for every eight clients, as required by regulation.
The findings include:
The current client census information and clinical staff hours were reviewed on May 14, 2015. There is currently one full time counselor at this facility, and one employee designated as a full time counselor who does not meet the experience requirements, therefore is not counted towards the overall ratio. There are a total of 40 full time equivalent hours dedicated to drug and alcohol services. The hours worked are divided by the standard work week of 35 hours, creating a full time equivalent of 1.142. Based on the census of twelve clients using the formula of 12/1.142 the staff client ratio is 11:1; which exceeds the required 8:1 ratio.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia's Winner Program Director will submit documentation to the Department that the counselor in question does meet the qualifications in both degree and experience. Documentation will be submitted by 08/19/2015.
If it is determined by the Department that the counselor does not meet qualifications for full time counselor, than the Program Director will change the counselor's position to Counselor Assistant III until qualifications are met.
If this change in position occurs, the Clinical Supervisor would assume a partial caseload. |