INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from June 4 to June 6, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, the Peniel Drug and Alcohol Residential Treatment Facility 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 the review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of six records reviewed.Findings:Six personnel records were reviewed on June 4, 2014. Employee #2 was hired as a counselor assistant on January 8, 2013 and promoted to a counselor on August 23, 2013. Employee # 2 received an Honorary Degree of Doctor of Ministry from the National Bible College and Seminary on August 23, 2013; however, an Honorary Degree not meet the educational requirements of a counselor.The Facility Director confirmed these findings.
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Plan of Correction
Employee #2 has been reassigned the position of counselor assistant and will be supervised by a primary counselor; therefore, this will qualify him to maintain a case load.
This staff has already completed the Domains of clinical experience under the Peniel Clinical Supervisor. He has submitted his letter of intent which states that he will agressively pursue the AACII level up to and including his full certification as a Certified Alcohol and Drug Counselor. Upon receiving his CADC credentials Employee #2 will serve as a primary counselor.
The qualifications for future clinicians will be carefully monitored, reviewed and approved by the Clinical Supervisor who will be responsible for making sure that DDAP qualification standards are properly met. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observation during the physical plant inspection, the facility failed to ensure that there were no heaters located within the facility that were not permanently mounted or installed.The findings include:A physical plant inspection was conducted on June 4, 2014 at approximately 1:30 PM.A portable space heater that was not permanently mounted or installed was observed in staff office 106. The facility director confirmed the findings.
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Plan of Correction
The space heater was immediately removed from the premises at the time of inspection.
The Vocational Department will be responsible for periodically checking the facility to make sure that there are no space heaters being used by any of the staff.
In addition a reminder memo has been sent to all staff rehearsing this policy. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all exits from the facility were unobstructed. The findings include:A physical plant inspection was conducted on June 4, 2014 at approximately 1:30 PM.The door in the admission office that is labeled as an exit was obstructed by excessive foliage that prevented the door from opening. Additionally, the door entering into the admission office is locked when the staff member assigned to that office is not present. By locking the entrance door to the admission office, the pathway to the exit door within the admission office would be obstructed. The double push bar doors in the gymnasium that exit to the long side extension of the building required excessive force to open. The doors were jammed with pink insulation within the vertical seems at the point where the doors close and latch shut. The facility director confirmed the findings.
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Plan of Correction
Regarding the Admissions Office: The Exit Sign was immediately removed at the time of the inspection and replaced with a sign that states "This Door Is Not An Exit" as was advised by the Inspector. Also, the foliage was removed from in front of this door.
With regard to the double push bar doors in the Gymnasium: WD40 lubricant was immediately applied as suggested by the Inspector and the narrow strip of pink insulation was immediately removed at the time of the inspection.
The staff member occupying that office will be responsible for making sure that this infraction does not recur. The vocational staff will periodically continue to check all exit doors and outside foliage near all of the exits to ensure that there is no obstruction. Furthermore,this specific door is no longer labeled an exit as suggested by the inspector. A sign has been placed on the door that states This Is Not An Exit. |