INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 15, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, SPHS Behavioral Health 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
The facility failed to ensure that each counselor met the qualifications for the position in one of two personnel records reviewed on January 15, 2019.
In personnel record #6 , the counselor did not meet the qualifications for the position of counselor based on a Master of Arts in Social and Public Policy and a Bachelor of Science in Communications.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Supervisor will be responsible for ensuring all applicants meet the qualifications for the counselor position. The Program Supervisor will document the degree and experience that qualifies the counselor in the employees file. If the candidate;s degree does not meet counselor role qualifications, the Program Supervisor will notate that the employee be designated as a counselor assistant for whom which weekly supervision and direct observation will be provided until the counselor assistant becomes eligible for the counselor qualifications set forth by DDAP regulations. The corrective action date was implemented on 1/30/19. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to document an informed and voluntary consent which included specific information disclosed, in seven of seven client records reviewed on January 15, 2019.
Client records # 1, 2, 3, 4, 5, 6 and 7 included releases of information to a funding agency that exceeded that which is allowed by 255.5.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Supervisor will meet with all program staff by 1/30/19 for the purposes of re-educating all staff on Drug and Alcohol Confidentiality and from refraining from exceeding the information allowed by 255.5 to funding agency. All staff will sign the supervision note verifying understanding of the expectation.
The Program Supervisor and Director will monitor the releases to ensure staff does not exceed the information allowed by 255.5.
The Director will replace releases to funding sources with releases that are restricted to only the 5 points. This implementation will be accomplished in the Electronic Heath Record (EHR) forms by 2/4/19. |