INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 27 - 31, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Tadiso, 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 and a plan of correction is due on November 24, 2008.
|
Plan of Correction
|
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.
|
Observations
Based on a review of fourteen personnel records on 10-27-08 and 10-28-08, and conversations with the director on 10-31-08, the facility failed to provide a counselor who meets the experience portion of the counselor qualifications in one of six personnel records where required.
Finding:
The facility appointed the staff person identified as employee # 6 to a counselor position, but the employee did not have the required one year of experience to qualify as a counselor.
|
Plan of Correction
The Director of Social Services will monitor and supervise employee #6 as a Counelor Assisitant for the next 90 days. Employee #6 is scheduled to complete his Master's Degree in December 2008 which will meet the qualifications for the Counselor position. Once verification is received, Employee #6 will be promoted to Counselor. If verification is not received in the ninety day timeframe, Employee #6 will remain at the assistant level and be supervised, trained and monitored as required by 704 guidleines. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of fourteen personnel and training records on 10-27-08 and 10-28-08, the facility failed to provide the required number of counselor training hours for 2007-08 training year in one of seven personnel and training records where required.
Finding:
The facility was not able to document a minimum of 25 hours of training for employee #10.
|
Plan of Correction
The Assistant Director of Social Services is in charge of the training for all counsleors. Within the next 90 days, all counseling staff are registered for 24 hours of qualified training. The training will be completed by January 31, 2009. Each counselor will be monitored and any deficiencies for the training year of 2008/2009 will be assessed and corrected prior to the end of the year in June ,2009. Most counseling staff has already received some training in the current year and will exceed the needed 25 hours. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of eighteen patient records on 10-28-08 and 10-29-08, the facility failed to provide written notification of termination for patients who are involuntarily discharged in one of two patient records where required.
Finding:
The facility did not provide written notification of termination for patient # 14 who was involuntarily discharged.
|
Plan of Correction
The Director of Social Services will review all involuntary discharges from the facility. He will monitor each case to ensure that the counselor has given written notice to the client and verify by signatures that the form was received by the client. The process will begin immediately. Writtten notices will be kept in a separate file as well as the individual client file for monitirng purposes. |