INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 14 - 15, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center, Inc., 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 and a plan of correction is due on March 18, 2011.
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Plan of Correction
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative policies and procedures, and an interview with the project director on February 15, 2011, the facility failed to complete the 2009 audit by the end of the project's fiscal year, as required by regulation.
The findings include:
A review of administrative policies and procedures, and an interview with the project director was conducted on February 15, 2011. Per regulation, the project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services. The project's fiscal year is from January through December. The project's audit for January 1, 2009 through December 31, 2009 was due to be completed no later than June 30, 2010. The project failed to document the completion of an annual audit for the 2009 fiscal year.
On February 15, 2011, the project director confirmed the 2009 audit had not been completed.
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Plan of Correction
The project director will submit a written request approved by the board of directors for an exception to this regulation so that we may fulfill the intent of the regulation without encurring the expense of a full audit.
If the exception request is denied we will have an independant public accountant complete a full audit of all financial activity for the organization for 2010 |
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 ensure that each counselor met the qualifications for the counseling position in two of two personnel records.
The findings include:
On February 14, 2011 seven personnel records were reviewed. Two counselors were hired since the last inspection, therefore, two personnel records were required to include documentation of the qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel record # 6.
Employee # 6 was hired as a counselor on August 25, 2010. The degree presented for Employee #6, for the position of counselor, is not listed as an appropriate qualification in either the standard or Licensing Alert # 3 - 10 regarding qualifications for clinical staff.
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Plan of Correction
Employee #6 was documented as a counselor and after review all documentation this will be corrected to reflect counselor assistant. The employee was informed of the error and signed a counselor assistant job description. The organization will continue to follow all regulations for training and supervision of counselor assistant for this employee.
The project director will have the clinical supervisor submit all education documentation with the staff assessment form for approval and instruction regarding the qualifications for the counselor position of any future staff member hired by the organization to ensure future compliance. |