INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Merakey Pennsylvania 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 document that each counselor met the qualifications for the position.Staff #5 was hired as a counselor on December 4, 2017. At the time of hire, staff #5 held a bachelor's degree in a qualifying field; however, he did not have at least one year of clinical experience documented. There was 4 months clinical experience documented in staff record #5.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the site inspection a deficiency was noted due to one counselor not having the required amount of clinical experience in a health or human service agency, preferably in a drug and alcohol setting. At the time of hire, the counselor only had 4 documented months of clinical experience. At the time of the licensing site inspection, the counselor had 14 months of clinical experience to now meet the requirement. Moving forward, the Hiring Manager will ensure that any counselor hired meets the qualifications for the position of counselor with their degree and required clinical experience dependent upon their degree. This matter will be referred to the Quality Control Division of the Quality Compliance Organization for investigation and follow up, which will include restitution for any identified overpayments. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
The facility failed to document that each counselor completed at least 25 hours of training for the 2017-2018 training year.Staff #3 is a counselor and was hired on February 12, 1996. The training year reviewed was July 31, 2017 to July 30, 2018. For the 2017-2018 training year, staff #3 had 18.75 training hours.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the site inspection a deficiency was noted due to one counselor not having completed the required 25 hours of training for the time period of 7/31/17-7/30/18. Following the completion of training attended by counselors, the Outpatient Director will log the training within the Learning Management System in order to accurately track the training hours of each counselor. Current training hours and the annual training plan will be utilized and discussed during each month's individual supervision with each counselor. The Clinical Supervisor will also suggest upcoming trainings and schedule the counselor for the trainings when they are available in order to ensure that the counselor is attending the required minimum amount of training hours per fiscal year. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facilty failed to document that an unusual incident report was filed with the Department within 3 business days following an event at the facility requiring the presence of police.Incidents occurred at the facilty which required police presence on December 4, 2017 and February 2, 2018. There was no documentation that an unusual incident report was sent to the Department within 3 business days. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the site inspection a deficiency was noted due to two occurrences where mental health outpatient consumers required police presence that a written unusual incident report was not filed with the Department within 3 business days following the unusual incident. Moving forward, after reviewing an incident report and identifying an incident that would fall into the category of an unusual incident, it will be reported by the Outpatient Director to the Department by utilizing the Unusual Incident Reporting Form-NON-NTP.PDF that was provided by the Department to the division email ? RA-DAAPI_Division@PA.GOV within 3 business days following the unusual incident. All staff on site will receive a refresher training on the workflow progress of all incident reports via the incident reporting policy. |