INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 16, 2013 to September 17, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mid-Atlantic Rehabilitation Services - A.T.P. 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 and the facility's Staffing Requirements Facility Summary Report (SRFSR) form completed on September 12, 2013, the facility failed to ensure that each counselor met the qualifications for the position of counselor in one of four personnel records reviewed.
The findings include:
On September 16, 2013, four personnel records and the facility's SRFSR form were reviewed for documentation of the qualifications for the position of counselor. The facility failed to ensure that each counselor met the appropriate clinical experience requirement for the position of counselor in one of four personnel records reviewed, specifically, personnel record # 5.
Employee # 5 is a counselor and was hired July 8, 2013. A review of the personnel record for employee # 5 indicated that the documentation for work experience requirements for the position was insufficient. The documentation indicated that employee # 5 had a Bachelor of Arts in Psychology but did not have any clinical experience.
The findings were confirmed during an interview with the facility director on September 16, 2013 at approximately 1:30 P.M.
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Plan of Correction
Employee #5 has been reclassified as a counselor Assistant as of 9/18/13 and will be supervised as per regulations applicable to a counselor assistant for their first year of employment. Upon completion of one year as a Counselor Assistant and meeting clinical requirements Employee #5 will be eligible for promotion to counselor. The facility through the project director will ensure that each new counselor meet the qualifications for the position of counselor before they are hired through utilization and review of the Addiction counselor job description which includes the options to meet the requirements of counselor and a review of their resume to ensure that they have met the experience necessary for the position of 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 records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form completed on September 12, 2013, the facility failed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff in one of one personnel record reviewed.
The findings include:
On September 16, 2013, one personnel record and the SRFSR form was reviewed to verify that employees had HIV/AIDS training. The facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS in one of one personnel record reviewed, specifically, personnel record # 4.
Employee # 4 is a counselor and was hired May 8, 2012. Employee # 4 was due to complete a minimum of 6 hours of HIV/AIDS by May 8, 2013. However, personnel record # 4 did not include documentation of HIV/AIDS training as of September 16, 2013.
The findings were confirmed during an interview with the facility director on September 16, 2013 at approximately 11:00 A.M.
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Plan of Correction
Employee #4 is rescheduled to attend HIV/AIDS training 10/15/13. The project director will obtain from employee #4 by 10/30/13 a copy of the certificate of training in HIV/AIDS and place in their personnel record. Personnel files for all employees will be audited by the Project Director at 6 months after hire for new employees and annually for current employees for the presence HIV/AIDS and TB/STD training within the first year of employment and that non-clinical staff complete HIV/AIDS and STD/TB training within two years of employment.
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705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on observations on September 17, 2013, the facility failed to maintain a minimum of two exits on every floor that are separated by a minimum distance of 15 feet on every floor.
The findings include:
A physical plant inspection was conducted on September 17, 2013. It was observed during the inspection from approximately 2:28 P.M. to 2:35 P.M. that on the first floor of the facility, the facility has one exit that the facility uses as the facility's front entrance and an exit. The second exit that the facility uses for the first floor is the rear exit that leads to the rear parking lot. In order to access the exit from the first floor, a person has to go down a half flight of stairs from the first floor. In the facility's basement, the facility has one exit that is used as a front entrance to a private practice doctor's office and an exit. However, the second exit that the facility uses for the basement is the same rear exit that leads to rear parking lot. In order to access the exit from the basement, a person has to go up a half flight of stairs from the basement.
The findings were confirmed during an interview with the facility director on September 17, 2013 at approximately 2:35 P.M.
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Plan of Correction
An exception letter from the Board of Directors was mailed requesting exception to the regulation was mailed 10/7/2013. If the exception is denied the facility will identify with the landlord and within local zoning regulations the installation of an exit that meets regulatory requirements within the DDAP regulations regarding physical plant. The project director in conjunction with the CEO will ensure the exit meets DDAP licensure standards. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained upon the date the facility began providing services at their new location or upon employment to perform assigned tasks during emergencies in eight of nine personnel records reviewed.
The findings include:
On September 16, 2013, nine personnel records requiring documentation that all personnel on all shifts had been trained to perform assigned tasks during emergencies were reviewed. The facility did not ensure that all personnel on all shifts completed emergency training upon the date the facility began providing services at their new location or upon employment in eight of nine personnel records reviewed, specifically, personnel records # 1, 2, 3, 4, 6, 7, 9, and 10.
Employee # 1 is the project director and was hired February 1, 2008. The facility began providing services at their new location on June 3, 2013. Employee # 1 was due to complete emergency training upon the date the facility began providing services at their new location. However, personnel record # 1 did not include documentation of emergency training for the facility's new location as of September 16, 2013.
Employee # 2 is the clinical supervisor and was hired for her current position May 28, 2012. The facility began providing services at their new location on June 3, 2013. Employee # 2 was due to complete emergency training upon the date the facility began providing services at their new location. However, personnel record # 2 did not include documentation of emergency training for the facility's new location as of September 16, 2013.
Employee # 3 is a counselor and was hired August 1, 2013. Employee # 3 was due to complete emergency training by August 1, 2013. However, personnel record # 3 did not include documentation of emergency training for the facility's new location as of September 16, 2013.
Employee # 4 is a counselor and was hired May 8, 2012. The facility began providing services at their new location on June 3, 2013. Employee # 4 was due to complete emergency training upon the date the facility began providing services at their new location. However, personnel record # 4 did not include documentation of emergency training for the facility's new location as of September 16, 2013.
Employee # 6 is a counselor and was hired August 11, 2008. The facility began providing services at their new location on June 3, 2013. Employee # 6 was due to complete emergency training upon the date the facility began providing services at their new location. However, personnel record # 6 did not include documentation of emergency training for the facility's new location as of September 16, 2013.
Employee # 7 is a counselor and was hired May 19, 2010. The facility began providing services at their new location on June 3, 2013. Employee # 7 was due to complete emergency training upon the date the facility began providing services at their new location. However, personnel record # 7 did not include documentation of emergency training for the facility's new location as of September 16, 2013.
Employee # 9 is a counselor and was hired March 14, 2013. The facility began providing services at their new location on June 3, 2013. Employee # 9 was due to complete emergency training upon the date the facility began providing services at their new location. However, personnel record # 9 did not include documentation of emergency training for the facility's new location as of September 16, 2013.
Employee # 10 is a counselor assistant and was hired March 1, 2013. The facility began providing services at their new location on June 3, 2013. Employee # 10 was due to complete emergency training upon the date the facility began providing services at their new location. However, personnel record # 10 did not include documentation of emergency training for the facility's new location as of September 16, 2013.
The findings were confirmed during an interview with the facility director on September 16, 2013 at approximately 1:30 P.M.
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Plan of Correction
On September 27, 2013 an in-service was held which included a training on the emergency plan and fire safety was held with staff. Annual emergency training documents are to be signed and placed in each staff members personnel files as evidence of having completed this in-service. On 9/27/13 # 1, 2, 3, 4, 6, 7, 9, and 10 were given emergency plan and fire extinguisher trainings as well as all other staff. Certificates of completion will be placed in clinician personnel files by 10/30/13. The Project Director will conduct on hire emergency training and fire drill training and ensure annual emergency and fire drill training is conducted annually for current staff. Evidence of completion in the form of completion certificates will be filed in personnel files by the project director. The Project Director will ensure that all new staff complete emergency training by conducting this training upon hire with each new staff member. |
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 facility failed to meet the requirements for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The document provided by the facility and identified as the annual audit of financial activities associated with the project's drug/alcohol abuse services for the 2012 calendar year was reviewed on September 16, 2013. The document presented as the facility's annual audit for the 2012 calendar year was completed on April 25, 2013. However, the signed and dated accountant's report included in the document stated, "A review is limited to presenting in the form of financial statements information that is the representation of management. We have not audited the accompanying financial statements and according do not express an opinion or any other form of assurance on them. Management has elected to omit substantially all of the disclosures, Statements of Retained Earnings and Cash Flows required by generally accepted accounting principals." The document offered as the audit for the calendar year 2012 did not meet the requirements.
The findings were presented during an interview with the facility director at approximately 3:30 P.M. The facility director did not confirm or dispute the findings.
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Plan of Correction
Mid Atlantic Rehabilitation Services will give all disclosure statements of retained earnings and cash flows required by generally accepted accounting principles to the agencies independent public accountant. The agencies IPA will complete a financial audit for the 2012 calendar year in accordance with generally accepted accounting principles. The CEO will ensure that this is complete. The agency moving forward will ensure that financial audits are completed annually. The CEO in conjunction with the Project Director will ensure the financial audit is completed on time within generally accepted accounting principles. |