INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 7, 2014 and February 10, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, ADAPPT House 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
Based on a review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in three of three personnel records.
The findings included:
Four personnel records were reviewed during the renewal process. Three personnel records were reviewed for documentation of the counselor meeting the qualifications for the position. The facility failed to provide documentation in personnel records # 1, 2 and 3.
Employee # 1 was hired as a counselor on May 14, 2013. The personnel record contained verification of a Bachelor of Arts degree in General Social Sciences. The Bachelor of Arts degree was reviewed by the Division and found not to meet the educational requirements for the position of counselor. Additionally, there was no documentation of a year of clinical experience in the record.
Employee # 2 was hired as a counselor on September 24, 2013. The personnel record contained verification of a Bachelor of Arts degree in psychology. There was no documentation of the one year of clinical experience required to meet the qualification for counselor.
Employee # 3 was hired as a counselor on January 2, 2014. The personnel record contained documentation of a Bachelor of Arts degree in Behavioral Health Studies. The record did not contain verification of the degree. Additionally, there was no documentation of the one year of clinical experience required to meet the qualification for counselor.
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Plan of Correction
Official verification of a Bachelor of Arts degree in Behavioral Health Studies related to employee #3 has been received by the ADAPPT H.R. Specialist who has placed it in the personnel file of Employee #3.
Employee #3 has signed a new job description (counselor assistant) due to the fact that she did not have the necessary clinical experience required to be a counselor.
The Clinical Supervisor shall provide the necessary supervision according to Chapter 704 Staffing Requirements.
Employee #1 has also signed a counselor assistant job description which has replaced the "counselor" job description that was found in his personnel file. Employee #1 shall follow the requirements set forth in 704.9 (c) 5
The Deputy Director/designee shall ensure that all documentation related to verification of qualifications is appropriately reviewed and verified and falls within the staffing requirements/guidelines set forth by the PA Department of Drug & Alcohol Programs/ Division of Drug & Alcohol Program Licensure.
The Deputy Director/designee, Clinical Supervisor, Director/designee, and HR Specialist shall meet to review the staffing guidelines and ensure that going forward a comprehensive reivew of paperwork presented by potential hires has been appropriately verified. |
705.6 (1) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(1) Provide bathrooms to accommodate staff, residents and other users of the facility.
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Observations
Based on a review of the physical plant, the facility failed to ensure that the water temperature did not exceed 120 degrees.
The findings included:
During the physical plant tour on February 7, 2014, at 11:30 a.m., the water temperature was checked. The water temperature was tested at 140 degrees.
The findings were confirmed with the staff member providing the tour.
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Plan of Correction
Maintenance personnel shall ensure that periodic checks are done on a daily basis to ensure that water temperatures in all bathrooms do not exceed 120 degrees. |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a review of the physical plant, the facility failed to ensure that smoking was limited to designated smoking areas.
The findings included:
During the physical plant tour on February 7, 2014, at 11:30 a.m., the men's bathroom was inspected. The bathroom had a strong odor of cigarette smoke.
The findings were confirmed with the staff member providing the tour.
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Plan of Correction
Although smoking at ADAPPT is limited to designated outdoor areas there are on occasion residents who choose to break rules. ADAPPT does not find this acceptable and shall ensure that monitors will continue to make rounds/inspections in the facility throughout the day. Although they may not actually be able to identify individuals who break the no smoking rule, the facility will impose sanctions related to no smoking areas that will affect community privlledges. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a review of the physical plant, the facility failed to ensure that exits are unobstructed.
The findings included:
During the physical plant tour on February 7, 2014, at 11:30 a.m., the facility exits were identified. The two exits located in the areas of the male and female bedrooms were found to be obstructed by snow and ice.
The findings were confirmed with the staff member providing the tour.
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Plan of Correction
Maintenance personnel has cleared all the ice and snow from the identified exits.
Maintenane personnel shall ensure that egress areas are clean and kept free from any obstrction including snow and ice. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a review of the physical plant, the facility failed to ensure that all fire extinguishers were inspected annually.
The findings included:
During the physical plant tour on February 7, 2014, at 11:30 a.m., the kitchen and food storage area were inspected. The fire extinguisher located in the garage food storage area had not been inspected since January 2013.
The findings were confirmed with the staff member providing the tour.
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Plan of Correction
The fire extinguisher located in the garage food storage area has been inspected and appopriately tagged.
The Maintenance supervisor shall ensure that all fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of administrative documentation, the facility failed to include a statement disclosing the names of officers, directors and principal shareholders in the annual report.
The findings included:
The annual report for the 2013 year was reviewed during the renewal process. The annual report failed to include a statement disclosing the names of officers, directors and principal shareholders, where applicable.
The findings were reviewed and confirmed with the facility director.
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Plan of Correction
A statement disclosing the names of officers, directors and principal shareholders has been added to the 2013 Annual Report.
Going forward the Facility Director shall ensure that this information is included in future annual reports. |
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 administrative documentation, the project failed to 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 findings included:
The facility's administrative records were reviewed for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services on February 7, 2014. The facility ' s fiscal year runs from January 1 to December 31.
The facility did not document an independent financial audit for the 2012 fiscal year.
An interview with facility director confirmed the findings.
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Plan of Correction
The Project Director will be responsible for meeting with corporate counsel to ensure that the annual audit of financial activities for the January 2012 through December 2012 fiscal year is completed.
The Project Director will follow up annually to ensure that the audit of financial activities is completed and available by June 30th of each year.
The Project Director will maintain communication and monitor progress of completed audit with corporate representatives at the beginning of each calendar year and request a completed annual audit of financial activities for the project so that it is available by June 30th. |