INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 22, 23, and 25, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on June 20, 2006.
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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
There was no documentation of the Department of Health review of an unrelated degree in personnel record #7. Department of Health staff were not able to be determined if the clinical staff person meets the qualifications for counselor.
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Plan of Correction
Staff person #7 obtained a Bachelor of Science degree in Social Services; which he used to obtain an Addictions Counselor position in the state of Maryland. Roxbury used this degree and experience to put him in the position of Counselor.
We have obtained the transcripts from his Bachelors degree ? as well as those from his Associates Degree ? and will forward to the Department of Health for review.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Individual training plans for 2006 are not completed for employee personnel records # 1, 3, 4, 6, & 8.
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Plan of Correction
It has been the policy of Roxbury Treatment Center that upon hire, each new employee is provided an Initial Training Plan. Then, on or about 90 days post hire, each employee is provided a Probationary Performance Evaluation. In addition, annually each employee is given an Annual Performance Evaluation which includes an Annual Training Plan.
For compliance with the 704.11 standard, Roxbury's "Work Performance Evaluations" policy has been revised to direct supervisors to develop an Individual Training Plan as part of each employee's Probationary Evaluation process. The goals/objectives of this plan will then be reviewed at the time of the employee's Annual review.
On 06/13/2006, the Human Resources Coordinator circulated a memo to all managers informing them of this new procedure and their responsibilities.
A copy of the new policy will be forwarded as part of this POC.
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The group counseling areas do not allow for visual privacy.
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Plan of Correction
A counselor's office and a counseling activity area contained windows that did not have window coverings for privacy.
On 06/09/2006, Roxbury's Plant Operations Manager installed blinds on the windows identified by the Licensing Specialists during the site survey. These blinds are operable and can be closed during counseling activities.
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709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
The document used by the facility to demonstrates that employees are informed of their rights was consistently missing from the personnel records and was not documented elsewhere.
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Plan of Correction
As part of the hiring process, all new staff are given an Employee Handbook, which contains information about Employee Rights. However, the handbook did not contain information regarding our policy of employee's right to review their personnel file. On 05/26/2006 Roxbury's Human Resource Coordinator drafted a verification form that all new hires will sign to verify that they have received a copy of this policy, and to demonstrate that they have been made aware of Employee Rights. This document was reviewed by the Licensing Specialist during the site visit and the form was put into use at that time.
On 06/13/2006 this Employee Rights policy, the sign-off form and a new copy of the Employee Handbook were circulated to all current staff. Staff returned the verification forms and the HR Coordinator put them in all existing personnel files.
A copy of this form is being submitted as part of this POC.
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709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The specific information to be disclosed is not consistently identified on the consent to release information form signed by the client.
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Plan of Correction
Roxbury was utilizing an alternate form to release information and coordinate services with patient's Primary Care Physicians. The form included all required components and was in compliance with DOH standards for confidentiality. However, as this form was structured differently than our other consents, staff were not consistently completing this form correctly.
To remedy the issue, Roxbury has removed this alternative release form from use and staff will utilize our standard Consent to Release Information form when communicating with Primary Care Physicians.
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