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Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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UHS RECOVERY FOUNDATION, INC.
2001 PROVIDENCE AVENUE
CHESTER, PA 19013

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Survey conducted on 01/14/2015

INITIAL COMMENTS
 
This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on January 13-14, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, UHS Recovery Foundation, 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:
 
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 personnel records, the facility failed to ensure that each counselor met the qualifications for the position of counselor in one of nine personnel records reviewed.

The findings include:

Nine personnel records were reviewed for documentation of the qualifications for the position of counselor. The facility failed to ensure that employee # 14 met the experiential qualifications for the position of counselor.

Employee # 14 was hired as a counselor on April 29, 2014. Employee # 14 has a qualifying Bachelor's Degree with a qualifying major. However, based on employee # 14's resume and employment application, employee # 14 did not have 1 year of the required clinical experience.

These findings were reviewed with a facility staff during the licensing process.
 
Plan of Correction
Plan of correction for Drug and Alcohol Licensure

704.7(b)

Human Resource Director will insure that the identified Counselor will have their position changed from Counselor to Counselor Aide until she meets the one year of required clinical experience effective 4/29/15. Affected employee has been given new job description which has been signed by employee and supervisor to reflect change. Human Resource Director and Facility Director will review credentials of all prospective staff candidates with regard to DOH Staffing Qualifications (CH. 704) to assure proper classification and compliance. Human Resource Director will perform quarterly personnel file audits to assure compliance.

 
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