INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 23-24, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Dars Inc. Supervised Independent Living Program, 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 ensure that each counselor met the qualifications for the position in one of two personnel records.
The findings include:
Two personnel records which required documentation of the qualifications for the position of counselor were reviewed on September 23, 2013. The facility failed to provide documentation of counselor qualifications in personnel record # 4.
Employee # 4 was hired as a counselor assistant on 6/4/12 and was promoted to counselor on 12/4/12. Employee # 4 has a Bachelor of Arts in Psychology which meets the educational requirements; however, she did not have the required one year clinical experience prior to being promoted to counselor. Employee # 4 only had 6 months of clinical experience at the time of promotion to counselor.
The Project Director and Facility Director confirmed the findings.
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Plan of Correction
Employee #4 has achieved the necessary 12 months of Clinical experience in a Drug and Alcohol position as of 6/4/13. The project director/facility director will ensure all future hires will be reviewed against the licensing standards to verify that previous clinical experience meets criteria for appropriate supervision as outlined in 704.7 (3), prior to being promoted to the position of Counselor. |
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 personnel and training records, the facility failed to provide documentation of TB/STD and HIV/AIDS training in three of four records.
The findings include:
Four personnel records which required documentation of a minimum of four hours of TB/STD training and six hours of HIV/AIDS training were reviewed on September 23, 2013. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training within the first two years of employment.
Employee # 4 was hired as a counselor assistant on 6/4/12. This employee was required to obtain four hours of TB/STD training by 6/4/13. Employee # 4 failed to obtain the training as of the date of the inspection.
Employee # 8 was hired as a youth care worker on 3/29/11. This employee was required to obtain four hours of TB/STD training and six hours of HIV/AIDS training by 3/29/13. Employee # 8 failed to obtain the training as of the date of the inspection.
Employee # 9 was hired as a youth care worker on 9/21/11. This employee was required to obtain four hours of TB/STD training and six hours of HIV/AIDS training by 9/21/13. Employee # 9 failed to obtain the training as of the date of the inspection.
The Project Director and Facility Director confirmed the findings.
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Plan of Correction
All DARS Inc. clinical staff will attend trainings on TB/STD, as well as HIV/AIDS within the first 12 months of employment with the agency. Employee #4 completed this requirement by attending a TB/STD training on 9/27/13. All other staff not employed in a clinical capacity will receive TB/STD and HIV/AIDS training within 24 months of employment with the agency. DARS, Inc. will utilize both external training opportunities and other approved curriculum to fulfill these training requirements. Certificates of completion will be filed in all employee training files with the agency. Employee #8 and Employee # 9 will attend both TB/STD and HIV/AIDS trainings within the facility on the first scheduled training date on 11/16/13. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation which included an assessment of the client's support systems and coping mechanisms in six of ten records.
The findings include:
Ten client records which required documentation of a psychosocial evaluation were reviewed on September 24, 2013. The facility failed to document a psychosocial evaluation which included an assessment of the client's support systems and coping mechanisms in client records # 3, 4, 5, 7, 8, and 10.
Client # 3 was admitted on 6/21/13 and was still an active client at the time of inspection. The psychosocial evaluation in this client record was missing an assessment of the client ' s coping mechanisms.
Client # 4 was admitted on 6/27/13 and was still an active client at the time of inspection. The psychosocial evaluation in this client record was missing an assessment of the client ' s coping mechanisms.
Client # 5 was admitted on 7/1/13 and was still an active client at the time of inspection. The psychosocial evaluation in this client record was missing an assessment of the client ' s coping mechanisms.
Client # 7 was admitted on 8/1/13 and was still an active client at the time of inspection. The psychosocial evaluation in this client record was missing an assessment of the client ' s coping mechanisms.
Client # 8 was admitted on 8/13/13 and was still an active client at the time of inspection. The psychosocial evaluation in this client record was missing an assessment of the client ' s support systems and coping mechanisms.
Client # 10 was admitted on 8/28/13 and was still an active client at the time of inspection. The psychosocial evaluation in this client record was missing an assessment of the client ' s coping mechanisms.
The Project Director and Facility Director confirmed the findings.
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Plan of Correction
All Interviewer's Assessments contained within Bio/Psycho/Social interviews will include a specific paragraph focusing on an assessment of the client's current coping mechanisms. This paragraph will discuss both positive and negative coping mechanisms with the intent of providing direction during treatment planning. The Interviewer's Assessment will also include a clear assessment of the client's support systems. For current files missing this information, an addendum will be added to the Bio/Psycho/Social assessment which identifies the coping mechanisms and support systems for each client. These assessments will continue to be reviewed by the Clinical Supervisor to ensure that all relevant information has been included in these areas. |