INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 12, 2007 through March 14, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on April 12, 2007.
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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
The project failed to provide documentation of counselor qualifications in personnel file numbers 3 and 4. Personnel file numbers 3 and 4 are relative to student interns with hours utilized to establish full-time equivalent ratios.
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Plan of Correction
L 0037: Aldie only utilizes student interns who are currently enrolled in a Masters degree-level program related to substance abuse treatment. While Aldie does verify that the intern is in a graduate program, documentation of the student's previously earned Bachelor's degree was not put into the student's personnel file. All current graduate interns now have the necessary documentation in their personnel file for a counselor position. The Aldie counseling staff member designated to supervise a new intern shall be responsible for obtaining the documentation necessary for qualifying the intern for a counselor position, and shall give these items to the administrative assistant for inclusion in the intern's personnel file prior to assigning clients to the intern. The program coordinator shall confirm that all necessary documentation is in the intern's personnel file before approving the assignment of clients to the intern. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The project failed to maintain written fire drill records to include the time of evacuation, exit route utilized and whether the fire alarm was operative.
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Plan of Correction
P P279: The fire drill log maintained by Aldie did not include categories for all the items that are to be included in the written record. The office manager, who is responsible for conducting the fire drills, has expanded the log to include all of the required items. The office manager shall insure that the fire drill log is completed properly after each drill. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
The project failed to provide documentation that alternate exit routes are prepared for the monthly fire drills.
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Plan of Correction
P P281: Records of monthly fire drills did not include a means to document that alternate exit routes were prepared for the drills. The office manager has added this to the monthly fire drill documentation, and shall ensure that the appropriate documentation is maintained for future drills. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
The project failed to provide written documentation that the fire alarm was set off during the monthly fire drills.
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Plan of Correction
P P285: Records of monthly fire drills did not include a means to document that the fire alarm was set off during the drills. The office manager has added this to the monthly fire drill documentation, and shall ensure that the appropriate documentation is maintained for future drills. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
The governing body failed to make the 2005/2006 report available to the public within six months of the end of the fiscal year.
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Plan of Correction
L 0135: Aldie placed a notice in the appropriate newspaper announcing the availability of Aldie's annual report eight months after the end of the 2005/2006 fiscal year, instead of within the required six month period. The administrative assistant shall send future notices to the appropriate newspaper within the required time period, and the executive director shall be responsible for insuring that notices regarding the availability of Aldie's annual report are published within six month of the end of the fiscal year. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
The project failed to make provisions through a written agreement with a licensed hospital or physician for 24-hour medical coverage.
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Plan of Correction
L 0167: Aldie has utilized the same physician for several years to provide 24-hour medical coverage. However, when it was time to renew this agreement, Aldie inadvertently sent the wrong agreement form to the physician. This error has been corrected, and Aldie now has the appropriate written agreement on file documenting 24-hour medical coverage. The administrative assistant shall send the physician the proper agreement form at the time of future renewals, and the quality assurance coordinator shall review this and the other written agreement forms for compliance with relevant regulations. |