INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on June 7-8, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Gaudenzia Together House were partially substantiated. Gaudenzia Together 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 and a plan of correction is due on A plan of correction must be submitted by August 31, 2010.
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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 the review of personnel records and an interview with the clinical supervisor, the facility failed to document the qualifications for the position of counselor in one of four personnel records.
The findings include:
Ten personnel records were reviewed on June 7-8, 2010. Of the ten records reviewed, four were identified as counselors, but the qualifications for the position of counselor were not included in personnel record #7.
Personnel record #7 contained college transcripts, but the transcripts did not indicate if a degree was awarded in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field.
An interview with the clinical supervisor was conducted on June 8, 2010. The clinical supervisor confirmed that personnel record #7 did not contain verification of the qualifications for the position of counselor.
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Plan of Correction
To ensure necessary documentation of employee qualifications are provided the following steps will be followed. Program Director will ensure that necessary documentation of qualifications is placed in the employee hire packet at the time of hire. In addition to this information going into the personnel file at the facility, a copy is also required to be sent to the corporate office prior to first day of employment. The administrative coordinator will conduct supervisory follow up by contacting the corporate office to confirm each new hire packet has been received with the proper contents. In addition the program director will be responsible for oversight and conduct random audits of personnel files on a monthly basis to ensure completeness of personnel records at both the facility and the corporate office. Full compliance will be met effective 09/03/2010. Personnel record # 7 has been reviewed and the required documentation of qualifications are in place. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of clinical supervision notes and an interview with the clinical supervisor, the facility failed to document direct observation supervision for counselor assistants.
The findings include:
Supervision notes were reviewed and an interview with the clinical supervisor was conducted on June 8, 2009. One employee was identified as a counselor assistant and required direct observation supervision. The facility did not document direct observation for personnel #9.
Personnel #9 was hired on 4/12/08 as a high school level counselor assistant with no previous clinical experience.
Personnel #9 was required to counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first three months of employment.
The documented supervision notes for personnel # 9 did not indicate if direct observation was occurring.
The client census forms provided by the clinical supervisor stated personnel #9 had a caseload of 5 clients.
The clinical supervisor confirmed that direct observation for personnel #9 had not occurred.
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Plan of Correction
Program Director will meet with clinical supervisor to review and train on the standards for supervision of all counselor assistants. This will include supervision, direct observation, and the documentation requirements. Clinical supervisor will supervise and document supervison according to standard for personnel file #9 for a period of nine months from the date of this submitted POC before consideration of completed supervision period. Program Director will be responsible for supervisory follow up and Division Director will be responsible for oversight.
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704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, completed by the facility on June 8, 2010 and an interview with the facility director, the facility failed to have at least one Full-Time Equivalent (FTE) counselor for every eight (8) clients.
The findings include:
The actual client to counselor ratio is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients ' treatment by the facility's standard workweek.
The facility ' s standard work week, as reported on the Staffing Requirements Facility Summary Report, was 40 hours per week.
On June 8, 2010 the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The form listed employee #3 (clinical supervisor), employee #4 (program supervisor/clinical supervisor), employee #5 (counselor II), employee #6 (counselor I), employee #7 (counselor), employee #8 (counselor), employee #9 (counselor assistant) for the clinical staff; however, employees #7 & 9 were not able to be counted in calculating the ratio. The facility lacked documentation for employee #7 to verify a degree to meet the qualifications for the position of counselor and employee # 9 was a counselor assistant that was still in the direct observation period.
Based the total number of hours per week that the facility reported the clinicians devoted to their clients (160), the total number of hours in the facility ' s standard work week (40), and the total number of active clients (38) on June 8, 2010, the facility failed to ensure that there was one FTE counselor for every eight clients. The Staffing Requirements Facility Summary Report indicated the client to counselor ratio was 10 clients for each FTE counselor.
160 hrs/40 hr workweek = 4 FTE 38 clients/4 FTE = 9.5 or 10:1.
The facility director signed the Staffing Requirements Facility Summary Report on June 8, 2010, to attest to the accuracy, veracity, and authenticity of the stated information.
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Plan of Correction
The facility will maintain compliance based on Staffing Requirements Facility Summary report. There will be one full-time counselor for every eight (8) clients. This standard will be in place by September 3, 2010. If the counselor/client begins to fall out of compliance, the managers will assume the role of clinicians until the counselor/client ratio is once again in compliance. This will be monitored by the Program Director, Clinical Supervisor and the Division Director for a period of not less than three months and on a quarterly basis thereafter.
The facility will obtain the documentation for employee #7 to verify a degree to meet the qualifications for the position of counselor. Employee # 9, counselor assistant, will have direct supervision the will be documented by the clinical supervisor. This will be monitored by the program director for a period of not less the three (3) months and on a quarterly basis thereafter. This standard will be in place no later than September 3, 2010.
Hiring managers, the division director and human resources will assure the all staffing requirements are in compliance based on the Staffing Requirements Facility Summary Report.
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