INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 1, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Care Center d/b/a SPHS Care Center 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
The facility failed to ensure that counselors met the qualifications for the position in two of ten personnel records reviewed on Febraury 1, 2018.Employee # 3 was hired for the counselor position on May 1, 2017. The employee's resume did not document the required 1 year of clinical experience in a health or human service agency.Employee # 8 was hired for the counselor position on July 5, 2017. The employee's resume did not document the required 1 year of clinical experience in a health or human service agency. The employee's major was not verified. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Supervisor will be responsible for ensuring that all applicants meet the qualifications for the counselor position. The Program Supervisor will document the degree and experience that qualifies the counselor in the employee's personnel file. If the candidate's degree does not meet counselor role qualifications, the Program Supervisor will notate that the employee be designated as a counselor assistant for whom which weekly supervision will be provided until the counselor assistant becomes eligible for the counselor qualifications set forth by DDAP regulations. This corrective action date was implemented as of 3/2/2018. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
The facility failed to document the required supervision of a counselor assistant in one of one personnel record review on February 1, 2018. Employee # 12 was hired as a counselor assistant on August 17, 2017. Documentation provided showed that the employee was provided supervision by a mental health supervisor for their mental health clients from August 17, 2017 to January 19, 2018. There was no documentation provided that the counselor assistant received supervision by drug and alcohol staff for their drug and alcohol clients. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Supervisor will be responsible for the provision, documenting, and filing of weekly supervision at a minimum for all counselor assistants until regulatory guidelines are met for the counselor assistant to be considered a counselor. The correction was implemented immediately effective on 2/2/18.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to update treatment and rehabilitation plans at least every 60 days in three of seven client records reviewed on February 1, 2018. Client # 1 had an update due by December 12, 2017. The update was completed on January 3, 2018.Client # 6 had an update due by December 26, 2017. There was no update documented. Client # 7 had an update due by August 7, 2017. The update was completed on September 7, 2017. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisors will hold a mandatory staff meeting to explain that treatment plans must be updated within a 60 day time frame. This correction was acccomplished on 2/6/2018 and will continue to be monitored by the Supervisors. |