INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 8, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Outlook Academy 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
The facility failed to assure that all counselors met the educational and experiential qualifications for their position.
Staff records were reviewed on January 8, 2018. Counselors #5 and #6 did not have documentation verifying that they met the experiential requirements for the position.
Counselor #5 was hired as a counselor on November 27, 2017 and holds a bachelor's degree that meets the educational requirements for the position of counselor; however, there was no documentation that Counselor #5 had at least one year of clinical experience.
Counselor #6 was hired as a counselor on September 5, 2017 and holds a bachelor's degree that meets the educational requirements for the position of counselor; however, there was no documentation that Counselor #6 had at least one year of clinical experience.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
New Outlook Academy's Human Resources Department and clinical management will thoroughly investigate qualifications of potential counselors and counselor assistants prior to hiring. All counselors hired will meet educational and experiential qualifications of the position. The two staff who were non-compliant will be placed as counselor assistants in accordance to the standards. Weekly supervision will be documented by a lead counselor and a clinical supervisor until they meet the standard for counselor. This facility will be in full compliance of this standard by January 31, 2018. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
The facility failed to document that alternate exits were used during fire drills.
The fire drills for the period of February 2017 - December 2017 were reviewed on January 8, 2018. All of the fire drill conducted for the period in review utilized the same exit route (exit #10). There were no alternate exits documented on any of the fire drill log forms reviewed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
New Outlook Academy staff will be re-educated by the Human Resources Department on fire drill procedures. Staff will be notified that they will need to utilize two different exits during fire drills. Fire drill log forms will document that an alternate exit was utilized. The Executive Director will review these logs to ensure that an alternate exit was used. This facility will be in full compliance of this standard by January 31, 2018. |