INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 13, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, LaRocco Counseling 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 one of twelve employee personnel records reviewed, the facility failed to provide documentation of the qualification of counselors for employee # 7. Employee # 7 was hired as a counselor on October 31, 2022 and was still in this position at the time of the inspection. Based on a review of employee # 7's personal record and resume, there was no documentation of at least one year of clinical experience or qualifying degree. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will closely monitor applicants and ensure they meet the criteria set forth.
If the degree or experience is in question, Project Director will reach out to a licensing specialist at DDAP
Employee #7 is no longer employed as a counselor and her last day is 1/27/2023
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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 (SRFSR) form, the facility failed to ensure that employee #12 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.Employee # 12 was hired as a counselor assistant on August 9, 2021 and promoted to and still in the position of counselor on November 1, 2022. Employee # 12 was due to have the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics no later than August 9, 2022. There was no documentation in the personnel file of the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics as of the date of the inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director and LaRocco Counseling supervisory staff will begin the process of assisting employees in obtaining valuable and required trainings at the point of hire.
In addition, LaRocco Counseling will utilize approved trainings outside of just DDAP to give more availability to staff.
Employee 12 is on the end of his notice; therefore, no plan of action is in place. His last day is next week. |
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
Based on one of six applicable employee personnel records reviewed, the facility failed to provide documentation of at least 25 clock hours of annual training required for a counselor for the training year April-March 2022.Employee # 10 was hired as a counselor on July 14, 2014 and was still in this position at the time of the inspection. After a review of employee #10 ' s personnel record, there were only 13 training hours documented.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director and LaRocco Counseling supervisory staff will begin the process of assisting employees in obtaining valuable and required trainings at the point of hire and continue to monitor during monthly supervision sessions.
In addition, LaRocco Counseling will utilize approved trainings outside of just DDAP to give more availability to staff.
Employee #10 has an individual training plan and has already completed required trainings for this year |
709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosureClient # 5 was admitted on May 5, 2021 and was discharged on October 6, 2022. An informed and voluntary consent from the client for the disclosure of information dated March 29, 2022 to a funding source did not include the purpose of the disclosure.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the February 18, 2022 annual licensing inspection.
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Plan of Correction
LaRocco Counseling has developed a policy and educated staff on it. The policy states that LaRocco Counseling staff shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to: Purpose of disclosure. Staff was educated on being specific to what the purpose of disclosure is; for example, funding.
LaRocco Counseling supervisory staff will follow up with this policy through routine auditing of client charts and staff supervision.
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709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include a dated signature of the client but instead had " verbal telehealth signature" in the signature line.Client # 3 was admitted on October 19, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated October 19, 2022 to a funding agency, PCP, family member, county office, and hospital did not have a valid signature by the client but instead had " verbal telehealth signature" in the signature line.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LaRocco Counseling has developed a policy and educated staff on it. The policy states that no verbal consents are permitted. In addition, it educated staff on what imminent danger is and when a release is not required.
This policy has already been discussed at most recent staff meeting and will continue to be monitored for adherence through chart audits and staff supervision by LaRocco Counseling supervisory staff. |
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
Based on two of five applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records # 1 and # 3.Client # 1 was admitted on May 24, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on May 26, 2022. A treatment and rehabilitation plan update was due no later than July 26, 2022 however, a treatment and rehabilitation plan update did not occur until September 26, 2022. The next treatment plan update was due to occur no later than November 26, 2022 however, a treatment and rehabilitation plan update did not occur until December 7, 2022.Client # 3 was admitted on October 19, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on October 26, 2022. A treatment and rehabilitation plan update was due no later than December 26, 2022 however, a treatment and rehabilitation plan update did not occur until January 6, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LaRocco Counseling has educated and trained staff and will continue to do so on treatment plan update criteria and time frames.
If a client is not present for some reason during the time frame, the counselor will complete the update within the 60 day time period and review with the client and obtain their signature upon their return.
This concern will continue to be addressed at staff meetings. In addition, LaRocco Counseling supervisory staff will assure compliance through chart auditing and staff supervision. |