INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on July 10, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, PA Treatment & Healing 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records on July 10, 2020, the facility failed to document that the facility director met both the education and experiential qualifications for the position.
Employee #2, whom was promoted to the facility director position on June 17, 2020, did not meet the experience requirements to be a facility director. At the time of the hire, the employee did not have three years of experience, which shall include supervision of others, direct service and program planning.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #2 who had been promoted to Facility Director on June 17,2020 did not meet the experience requirements to be a facility director at that time.
Employee #2 has been removed from the position of facility director at this time and has been returned to her position of Lead Counselor to allow her to obtain the required experience for that position. She will be scheduled to attend the clinical supervision training and will work to obtain the required experience to allow her to move into that position as soon as she meets all requirements for that position. In the interim the Program Director will continue to function in capacity of facility director for the Altoona location. The agency will be in compliance with this standard as of August 28,2020 |
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 on July 10, 2020, the facility failed to document that each counselor met both the education and experiential qualifications for the position.
Employee #4, whom was hired as a counselor on July 23, 2018, did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have one year of clinical experience required to be a counselor.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on the review of personnel records on July 10,2020 Employee #4 had been hired as a counselor on July 23, 2018 had failed to meet the experience requirements to be a counselor at the time of hire.
Employee #4 has now obtained the clinical experience requirements of one year to be a counselor at this time and will continue to be monitored by the Clinical Supervisor to ensure that he continues to meet all requirements to remain in the position of counselor from this point forward.
The agency will be in compliance with this standard as of 8/28/2020 |
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 records and the facility's Staffing Requirement Facility Summary Report form on July 10, 2020, the facility failed to ensure that employee's #4, 5 and 7 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 #4 was hired as a counselor on July 23, 2018 and was due to have the communicable disease trainings no later than July 23, 2019. There was no documentation of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #5 was hired as a counselor on September 8, 2018 and was due to have the communicable disease trainings no later than September 8, 2019. There was no documentation of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #7 was hired as a counselor on May 20, 2019 and was due to have the communicable disease trainings no later than May 20, 2020. There was no documentation of the completion of the TB/STD training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The agency failed to ensure that employee #4, #5, and #7 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.
Each employee has been addressed regarding the necessity of scheduling the HIV/AIDS and TB/STD required DDAP trainings as soon as available through the DDAP training site to fulfill this state requirement. The Clinical Supervisor and Facility Director will monitor each employee for compliance with this direction to obtain all missing required trainings.
The agency will be in compliance with this standard as of December 31, 2020 |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
A review of the March 2018 through June 2020 fire drill logs was conducted on July 10, 2020. The facility failed to include documentation of whether the fire alarm or smoke detector was operative at the time of the drill.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to include documentation of whether the fire alarm or smoke detector was operative at the time of the drill.
The Clinical Supervisor and Facility Director will ensure that the fire alarm or smoke detector is operative at the time of all fire drills.
The agency will be in compliance with this standard as of 8/30/2020 |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on review of fire drill logs for March 2018 through June 2020 on July 10, 2020, the facility failed to show documentation that a fire alarm or smoke detector was set off during each fire drill.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to show documentation that a fire alarm or smoke detector was set off during each fire drill.
The Clinical Supervisor and/or the Facility Director will show documentation that a fire alarm or smoke detector was set off during each fire drill from this point forward.
The agency will be in compliance with this standard as of 8/30-2020 |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the policy and procedures manual and client rights documentation on July 10, 2020, the project failed to include all parts of the client rights regulation. The project failed to include that a client may not be discriminated against based on creed, sex, color and national origin.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project failed to include all parts of the client rights regulation. The project failed to include that a client may not be discriminated against based on creed, sex, color and national origin.
The Project Director will update the client rights to include that a client may not be discriminated against based on creed, sex, color, and natural origin and will instruct the Clinical Supervisor to have all counselors provide each active client with an updated client rights and document in the chart that each client has reviewed this form.
The agency will be in compliance with this standard as of September 30, 2020 |