INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18, 2020 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, Addiction and Behavioral Counseling Associates LLC DBA Matrix Treatment Center 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 each counselor met the qualifications for the position in one of seven counselor personnel records reviewed.Employee #7 was hired for the position of counselor on May 18, 2020. Employee #7 has a Bachelor of Arts in Political Science and does not meet the educational qualifications for the position of counselor. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based upon a review of employee records, the facility failed to ensure that an employee hired to be a counselor met at least one of the qualifications outlined under 704.7 (b), Immediately and moving forward, the Facility Director will review each candidate's qualifications and ensure that the candidate qualifies for a position as outlined under 704.7(b). All new counselors hired will meet both the education and experience requirements for the position of counselor. Facility Director discussed options with employee #7 and decision was made. |
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
The facility failed to have a counselor assistant supervised by a full-time clinical supervisor or a counselor. One counselor assistant, Employee #2, is supervised by the facility director.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately and moving forward, the counselor assistant will be supervised by a full time counselor that meets § 704.7 qualifications. |
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.
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Observations
The facility failed to document monthly fire drills. Facility was given approval to begin providing services on October 10, 2019. Fire drills were not documented for November 2019 and December 2019.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately and moving forward the Facility Director will ensure that an unannounced fire drills will occur at least once a month even when the facility does not have clients. A counselor will conduct a random and unannounced fire drill at least once a month, and complete required documentation. The Facility Director will review the fire drill log monthly to ensure compliance. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
The facility failed to document fire drills during sleeping hours. Facility was given approval to begin providing services on October 10, 2019. A fire drill during sleeping hours was not documented.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately and moving forward the Facility Director will ensure that an unannounced fire drills will occur during sleeping hours at least once every six months. The midnight counselor technician will conduct a random and unannounced fire drill at least once every 6 months during sleeping hours, and complete required documentation. The Facility Director will review the fire drill log monthly to ensure compliance. |
715.14(d) LICENSURE Urine testing
(d) A narcotic treatment program shall ensure that a laboratory that performs the testing required under this section shall be in compliance with applicable Federal requirements, specifically the Clinical Laboratory Improvement Amendments of 1998 (42 U.S.C.A. §§ 201 note, 263 and 263a notes), and State requirements, specifically the Pennsylvania Clinical Laboratory Act (35 P.S. §§ 2151-2165) and Chapter 5 (relating to clinical laboratories).
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Observations
The facility failed to provide a CLIA Certificate of Waiver, and a PA Department of Health lab certificate. Facility provided a general letter regarding the use of CLIA waived tests, but a CLIA Certificate and a PA DOH lab certificate is still required.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has completed and submitted the necessary paperwork for a CLIA Certificate and PA DOH lab certificate. Both will be on file at the facility. |
715.20 LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
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Observations
The facility failed to document a written transfer procedure that includes who is responsible and how it will be documented. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has updated the patient transfer policy to include who is responsible for a patient transfer and how it will be documented. The Facility Director or a Counselor will be responsible for a patient transfer, and a notice of discharge will be completed as documentation of the patient transfer. |