INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 15, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Community Guidance Center 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 #5 who was hired as a counselor on January 4, 2022, did not meet the experience requirements to be a counselor. At the time of the hire, 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
D&A Supervisor (Masters Level Therapist) will provide supervision and direct observation with the bachelors level therapist to ensure appropriate skills and documentation for the consumer. Bachelor's level therapist will be under supervision for 1 year. Upon hiring an individual that doesn't meet the requirements the OP Director or D&A Supervisor will provide clinical supervision to assure adequate delivery of services. With current individuals that do not meet the requirements the OP Director or D&A Supervisor will provide supervision and observe sessions. |
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 a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven records reviewed.
Client #5 was admitted on January 12, 2021 and discharged on June 9, 2022. A treatment plan update was completed on February 7, 2022 and the next update was due no later than April 7, 2022; however, it was completed on April 18, 2022. Additionally, a treatment plan update was completed on July 14, 2021 and was due no later than September 14, 2021; however, it was completed on October 11, 2021.
Client #6 was admitted on June 28, 2021 and discharged on April 13, 2022. A treatment plan update was completed on September 8, 2021 and the next update was due no later than November 8, 2021; however, it was completed on November 24, 2021. Additionally, a treatment plan update was completed on January 18, 2022 and the next update was due no later than March 18, 2022: however, no update was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The OP Director or the D&A Supervisor will provide the therapist will be provided end dates for treatment plans and provided a list of consumer's on their caseload with treatment plan update dates. They will be provided this on a monthly basis. The OP Director or D&A Supervisor will follow up with the therapist in regards to the treatment plan updates. |