INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 6 - 7, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Davis Archway House 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
At the time of the annual licensing inspection on September 6 & 7, 2016, the facility failed to ensure each counselor meet the qualifications for their positions. Employee # 2 was promoted to a counselor on April 25, 2016, but does not meet the educational requirements. Employee # 5 was hired as a counselor on July 25, 2016, but does not meet the experiential requirements. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor at our facility made the determination of whether Employee #2 was to be promoted from the position of counselor assistant to counselor. The Clinical Supervisor also made the determination of position for Employee #5, starting them as counselor versus counselor assistant. Effective immediately, the Clinical Supervisor will no longer be involved in any personnel decisions. The Executive Director will assume all responsibility for making decisions regarding job position and dates of promotion. Along with the Executive Director, the Assistant Director will be responsible for monitoring all new hires to ensure they meet the requirements for the position. Employee #2 will remain in the position of Counselor Assistant and will be promoted to Counselor once his degree is completed and he meets the requirements for the position. Employee #5 was terminated and is no longer employed by our agency. |
709.28 (c) 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.
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Observations
The facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in three of ten client records reviewed during the annual licensing inspection on September 6 - 7, 2016.Client # 7 - A release of information form for a funding source was signed on June 22, 2016, but failed to include a relevant purpose for the disclosure.Client # 8 - A release of information was not signed for information that was disclosed in the form of a letter. The letter was sent August 12, 2016.Client # 9 - A release of information was not signed for information that was disclosed in the form of a letter. The letter was sent July 14, 2016 These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Director has reviewed valid consent forms with all clinical staff members at the morning staff meeting held September 21, 2016. All components of the consent forms were reviewed and all clinical staff members were retrained to fill them out properly. All staff have been trained how to fill out valid consent forms. At our next scheduled monthly staff meeting on October 13, the Executive Director will again review the information to ensure compliance. The Assistant Director will also check consent forms during regular chart audits. |