INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 9-12, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Teen Challenge Training 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 April 4, 2010.
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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 ensure that each counselor met the qualifications for the position in two of two personnel records reviewed
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The findings include:
On March 9-12, 2010, seven personnel records were reviewed. Two personnel records were required to have documentation of the qualifications for the position of counselor. The facility failed to provide documentation that an employee met counselor qualifications in personnel records # 4 and 5.
Employee # 4 was hired as a counselor on December 14, 2009. The employee does not have the required one year of clinical experience and does not meet the qualifications of counselor.
Employee #5 was hired as a counselor on March 1, 2010. Employee # 5 does not meet the educational requirements for the position of counselor.
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Plan of Correction
Employee #4's status as a Counselor has been changed to Counselor Assistant. He has begun close supervision for a total of six months. He will have one year of clinical experience before consideration is made to change his status to Counselor.
Employee #5's status as a Counselor has been changed to Counselor Assistant. He will have three month of direct observation then nine months of close supervision. He will develop a plan of education to work towards his CAC or bachelors' degree in a related field.
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records and a staff interview, the facility failed to document complete and legible physical examinations in four of six client records.
The findings include:
Six records were reviewed on March 11-12, 2010. Physical examinations were required in six client records. The facility failed to document on the physical examination the general appearance and physician impressions in four of six client records. In one of six client records the physicians handwriting was not legible.
Client record # 1, 3, 4, and 5 did not contain the general appearance and physician's overall impression of the client.
Client record # 3 was not legible. An interview with staff, during which time documentation was requested to be read, confirmed the documentation to be be unreadable.
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Plan of Correction
A letter will be written and sent to each induction center by April 2, 2010 addressing the facts that the doctor's who fill out the medical forms are not writing down the general appearances of the clients and the physician's overall impressions of the client and requesting that Doctors write legible.
To help assure they do so a cover sheet be attached to the medical form asking the doctor's write or print legibly and to be sure they write down the client's general appearances and his overall impressions.
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