INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 7-9, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Services of Beaver Valley - Vanport, 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 January 3, 2011.
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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 and an interview with the executive director, the facility failed to ensure that each counselor met the qualifications for the position in two of six personnel records.
The findings include:
On December 7, 2010, eight counselor personnel records were reviewed. Six of the counselors reviewed were new hires and their qualifications were reviewed. All six counselor personnel records were required to have documentation of the qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel records # 8 and 10.
Employee # 8 was hired as a counselor on October 4, 2010. Employee # 8 has a Bachelor of Arts in Psychology, which meets the educational requirements; but does not have one year of required clinical experience. Employee # 8 does not have any documentation of clinical experience.
Employee # 10 was hired as a counselor on June 7, 2010. Employee # 10 has a Bachelor of Science in Human Services which meets the educational requirements; but does not have one year of required clinical experience. Employee # 10 does not have any documentation of clinical experience.
An interview took place with the executive director on December 7, 2010 at which time additional documentation of clinical experience for the above mentioned counselors was requested. The executive director confirmed that no additional documentation of clinical experience was available for review.
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Plan of Correction
Personnel charts for counselors #8 and #10 reflect their employment status as Counselor Assistant. For at least the next 6 months, the Counselor Assistant will receive documented supervision, observations and a semiannual performance evaluation. The Lead Counselor will be responsible to provide close supervision and document the actions taken. This process will be monitored by the Executive Director. The compliance process will begin in January 2011 and continue until the Counselor Assistant is promoted to 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 training records and an interview with the executive director, the facility failed to provide documentation of TB/STD and/or HIV/AIDS training in three of twelve personnel training records, as required by regulation.
The findings include:
Twelve personnel training records were reviewed on December 7, 2010. Twelve personnel training records were required to have documentation of TB/STD and HIV/AIDS training. Per regulation, staff persons shall receive a minimum of 4 hours of TB/STD training and 6 hours of HIV/AIDS training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training with the first 2 years of employment. The facility did not provide documentation of TB/STD and/or HIV/AIDS training in personnel training records # 4, 5 and 12.
Employee # 4 is a counselor and was hired February 1, 2009. TB/STD and HIV/AIDS training was due to be completed no later than February 1, 2010. The facility failed to provide documentation of TB/STD and HIV/AIDS training for this employee as of December 9, 2010.
Employee # 5 is a counselor and was hired April 6, 2009. TB/STD training was due to be completed no later than April 6, 2010. The facility failed to provide documentation of TB/STD training for this employee as of December 9, 2010.
Employee # 12 is a support staff and was hired November 5, 2007. TB/STD and HIV/AIDS training was due to be completed no later than November 5, 2009. The facility failed to provide documentation of TB/STD and HIV/AIDS training for this employee as of December 9, 2010.
The executive director was interviewed on December 7, 2010 and confirmed that these employees had not completed TB/STD and/or HIV/AIDS training.
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Plan of Correction
Each new employee will receive a copy of the General Training Requirements. The Clinical Supervisor and Lead Counselor will reinforce the importance of attending initial trainings within the timeframe indicated in the regulations. The Personnel Person will provide training dates and training sites to all employees and the supervisors to insure they attend manditory training. The overall process will be ongoing and monitored by the Executive Director. This process will being January 2011. (Note: TB/STD and HIV/Aids training has been scheduled for January 28, 2011. All individuals needing this training are required to attend). |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of the annual audit of financial activities, the policy and procedure manual and an interview with the executive director, the project failed to complete an annual audit of financial activities until fourteen months after the end of the fiscal year.
The findings include:
The annual audit of financial activities for year ending June 30, 2009 and policy and procedures were reviewed on December 7, 2010. Per regulation, the project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services. The project failed to complete an audit in a timely fashion. The annual audit of financial activities for year ending June 30, 2009 was not completed until August 25, 2010.
The executive director was interviewed on December 7, 2010 and confirmed that the audit for year ending June 30, 2009 had not been completed until August 25, 2010.
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Plan of Correction
DASBV has had difficulty getting the annual audit on track to comply with Fiscal Management policy. Two previous accountants, under previous Directors, had not provided records to the auditors in a timely manner, therefore, the audits were not completed within the required 6 months.
In May 2010, a new, well qualified accountant was hired to work with our auditors in order to meet audit timeframes. The auditors are also aware of these required timframes. Both our accountant and the auditors are currently working together in order
to meet audit timeframes.
The Auditors will start the 2010 audit in February, 2011 and it will be completed on or before June 30, 2011.
The Executive Director is responsible for monitoring this process and insuring timeframes are met. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of the policy and procedure manual, client records and an interview with the executive director, the facility failed to document follow up contact in seven of seven outpatient client records.
The findings include:
Eight outpatient client records were reviewed on December 8-9, 2010. Seven of the client records reviewed required a one month follow up contact, per agency policy. The facility did not document follow up contact in client records # 13, 14, 15, 16, 17, 18 and 20.
Client #13 was admitted on June 28, 2010 and discharged on September 14, 2010. Follow up contact was due by October 14, 2010. There was no documentation of follow up contact in client record #13 as of December 9, 2010.
Client #14 was admitted on July 20, 2010 and discharged on September 21, 2010. Follow up contact was due by October 21, 2010. There was no documentation of follow up contact in client record #14 as of December 9, 2010.
Client #15 was admitted on May 19, 2010 and discharged on September 13, 2010. Follow up contact was due by October 13, 2010. There was no documentation of follow up contact in client record #15 as of December 9, 2010.
Client #16 was admitted on July 12, 2010 and discharged on October 27, 2010. Follow up contact was due by November 27, 2010. There was no documentation of follow up contact in client record #16 as of December 9, 2010.
Client #17 was admitted on August 3, 2010 and discharged on September 2, 2010. Follow up contact was due by October 2, 2010. There was no documentation of follow up contact in client record #17 as of December 9, 2010.
Client #18 was admitted on August 17, 2010 and discharged on October 26, 2010. Follow up contact was due by November 26, 2010. There was no documentation of follow up contact in client record #18 as of December 9, 2010.
Client #20 was admitted on August 24, 2010 and discharged on September 23, 2010. Follow up contact was due by October 23, 2010. There was no documentation of follow up contact in client record #20 as of December 9, 2010.
An interview with the executive director took place on December 9, 2010. The executive director confirmed that there was no follow up documentation in the aforementioned client records.
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Plan of Correction
In January, the Clinical Supervisor is providing case management training to all counselors. Once a client is assigned to a counselor, he or she will be responsible for timely case management from the beginning of treatment to the 30 day follow-up. This process will be ongoing and monitored by the Clinical Supervisor. |