INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 7, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Adult & Teen Challenge 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 a review of personnel records, the facility failed to document that each counselor met both the education and experiential qualifications for the position.
Employee #8, who was hired as a counselor assistant on May 16, 2022, and was promoted to a counselor on November 16, 2022 did not meet the experience requirements to be a counselor. At the time of the promotion, the employee did not have one year of clinical experience required to be a counselor with a bachelor's degree.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
L0037.
Director of outpatient services reviewed staffing requirements with Lead Counselors. Employee number #8 will receive supervision required to the counselor assistant role until at least one year past the May 16,2022 hire date. Promotion to counselor will be dependent on at least one year as counselor assistant and positive assessment from supervisor. |
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
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide close supervision by a trained counselor or clinical supervisor for the first 6 months of employment.
Employee #8 was hired on May 16, 2022 as a counselor assistant and was promoted to counselor on November 16, 2022. He had no documentation of weekly close supervision.
Employee #9 was hired on October 17, 2022 and was still employed in that position at the time of the inspection. She had no documentation of weekly close supervision.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 11, 2022 inspection.
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Plan of Correction
L0049 Director of Outpatient Services reviewed requirements of supervision of a counselor assistant with Lead Counselor. Director and Lead Counselor will immediately start providing documentation of weekly, close supervision for all counselor assistants. Director and Lead Counselor will identify any Counselor Assistant in the future and review requirements for each new counselor assistant as they begin employment |
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, the facility failed to ensure that employees 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 #8 was hired as a support staff on February 17, 2020 and was due to have the communicable disease trainings no later than February 17, 2022. There was no documentation in the personnel file of the completion of the HIV/AIDS or the TB/STD trainings as of the date of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the March 11, 2022 and June 25, 2021 inspections.
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Plan of Correction
L0067
Director reviewed core training requirements with Lead Counselors. All staff will schedule core training within first year to meet competency and compliance. The Quality Assurance Department will review staff training grids quarterly to ensure compliance. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of one applicable client record.
Client #7 was admitted on April 15, 2022 and discharged on December 16, 2022.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
L0333
Discharge Processed were reviewed with clinical staff to ensure future compliance. The Quality Assurance Department will monitor charts for compliance with written discharge notices. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based upon a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to comply with plans of correction that were approved by the Department. Plan of corrections for communicable disease training were submitted and approved by the Department for the March 11, 2022 and June 25, 2021 annual licensing inspections. Communicable disease training was again found to be a deficiency in the February 7, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A040
The Director of Outpatient Services and Lead Counselor identified available in-person and on-demand DDAP approve communicable disease trainings available for staff. Lead Counselors and the quality assurance department, will ensure that all staff have required communicable disease trainings by April 27, 2023. |