INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 21 - 23, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Snug Harbor Rehabilitation and Recovery, LLC 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major 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 and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in 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 and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in 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 and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to document that the facility director met the qualifications for the position in one of one record.Staff #1 was hired in a non-clinical position on June 8, 2020 and promoted to the facility director position on April 18, 2022. Staff #1 meets the experiential requrirements for the position; however, the degree that staff #1 holds does not meet the educational requirement. Staff #1 provided documentation of an Associate of Arts degree, but there was no major associated with the degree.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director requested additional verification that was not seen by surveyor and has received the requested documentation from both colleges attended with transcripts that detail her focus was psychology.
IN addition to the 9 years of experience, the letter from the University, transcripts received, and copy of degree received it is clear she has met the requirements for the position.
Facility Director has enrolled in a college to complete her BA in Psychology which she is only a few credits shy of.
Upon hiring of an employee all required documentation including transcripts for Clinical team and HR will monitor all employee files to ensure required documentation is current and complete in all employee files and will be available for review at all times.
Executive Director will ensure this is completed. |
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 document that each counselor met the qualifications for the position in one of two records.Staff #2 was hired as a counselor assistant on February 11, 2022 and promoted to a counselor on May 9, 2022. Staff #2 is a certified peer specialist and a certified recovery specialist, with a high school diploma. Prior to being hired at the facility, there was no documented clinical experience. Staff #2 does not meet the educational or experiential requirements for the position of counselor.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee will be working as Counselor Assist. The employee has applied for the CAAC (Certified Associate Addiction Counselor) certification and will remain a Counselor Assist until this certification is achieved.
Once this certification is obtained the employee will be eligible for the role of Counselor.
All counselors hired in the future will meet both educational and experiential requirements.
Both HR and Facility Director will ensure this is implemented. |
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 records, the facility failed to document that staff completed TB/STD and HIV/AIDS training using a Department approved curriculum in two of two personnel records.Staff #1 was hired as a support staff on June 8, 2020 and promoted to facility director on April 18, 2022. Approved TB/STD and HIV/AIDS training was due to be completed by June 8, 2022. Staff #1 did complete some TB/STD and HIV/AIDS training; however, it was not documented to be utilizing Department approved curriculum.Staff #2 was hired as a counselor assistant on February 11, 2022 and promoted to counselor on May 9, 2022. Approved TB/STD and HIV/AIDS training was due to be completed by February 11, 2023. Staff #2 did complete some TB/STD and HIV/AIDS training; however, it was not documented to be utilizing Department approved curriculum.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff have been mandated to visit a DDAP approved training site for HIV/AIDS
TB/STD. This includes all current employees.
All future employees will be required to follow the same instruction.
HR and Facility Director will ensure training is completed. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.The fire drill logs were reviewed for the timeframe of March 2022 - February 2023. There was only one fire drill during sleeping hours conducted during that timeframe, which was documented on June 8, 2022. Another fire drill during sleeping hours was due to be completed by December 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff have been re-educated on the procedure of Fire drills. Special attention was given to those drills conducted every 6 months during sleeping hours. These drills will be executed after the 10pm scheduled bedtime.
The Property Manager will ensure this process is adhered to and monitor proper documentation is completed. |