INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 16, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Creative Health Services 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:
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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 eight personnel records, it was determined that one employee hired as a counselor did not meet the qualification requirements for the position.Employee #4 was hired as a counselor on April 25, 2022 and was current in that position at the time of the inspection. At the time of hire, the employee did not have a qualifying degree.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of program will ensure that prior to hiring any new counselor, a thorough review of applicant's resume and transcripts as well as degree, diploma, and certification will be conducted, to meet the requirements of regulation 704.7.
This employee has been provided with appropriate supervision for their credentials, and will continue to be provided with appropriate supervision and monitoring by direct Supervisor.
Employee # 4 is no longer in the counselor position effective 2/17/2023. Employee is now a Counselor Assistant. |
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 nine personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one applicable employee received the minimum of 4 hours of TB/STD training within the regulatory timeframe.Employee #9 was hired as a support staff member on October 29, 2020 and was due to have the communicable disease trainings no later than October 29, 2022. However, there was no documentation of the completion of the TB/STD training as of the date of the inspection.This is a repeat citation from the March 3, 2022 annual licensing inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director and Supervisors will monitor and review in individual supervision with each staff member, what trainings are required to ensure these trainings are completed within the timeframe specified in regulation 704.11. This employee will complete the required training on April 28, 2023. Supervisors will remind staff in weekly supervision, of this upcoming training. The Director will ensure that staff are in compliance with completing all required trainings within the regulatory timeframe. |
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 a review of seven client records, the facility failed to ensure that consent to release information forms included the signature of the client in three records reviewed.Client #4 was admitted on April 12, 2022 and discharged on June 22, 2022. The record contained a consent to release information form to a family member signed by the witness on May 4, 2022, that was missing the signature of the client.Client #5 was admitted on April 22, 2022 and discharged on August 11, 2022. The record contained a consent to release information form to an employer signed by the witness on August 25, 2022, that was missing the signature of the client.Client #7 was admitted on July 24, 2019 and discharged on November 22, 2022. The record contained a consent to release information form to a treatment provider signed by the witness on April 22, 2022, that was missing the signature of the client.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
With the direction of the Director and Supervisors, staff will obtain only physical signatures from clients in order to release information to any identified person or facility as stated in regulation 709.28.
Ongoing monitoring will be completed by direct Supervisors. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in three of seven applicable records reviewed.Client #1 was admitted on March 21, 2022 and was active at the time of the inspection. The treatment plan completed on September 15, 2022, indicated that the client was to receive two group sessions per week; however, the record only contained documentation of one group session during the week of October 31, 2022.Client #3 was admitted on July 28, 2022 and was active at the time of the inspection. The treatment plan completed on November 21, 2022, indicated that the client was to receive two group sessions per week; however, the record only contained documentation of one group session the week of November 28, 2022 and no group sessions the week of December 5, 2022.Client #6 was admitted on April 25, 2022 and discharged on December 19, 2022. The treatment plan completed on August 29, 2022, indicated that the client was to receive one individual session per week; however, the record did not contain documentation of an individual session the weeks of October 3, 2022 and October 10, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
With the direction of Director and Supervisors, all Counselors will assure that counseling services are provided according to the individual treatment and rehabilitation plan as stated in regulation 709.92.
Ongoing monitoring will occur by the Direct Supervisors. |