INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 29-30, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Directions Healthcare, LLC 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 staff records, the facility failed to document that each counselor met the educational and experiential requirements for the position.
Staff #8 was hired as a counselor assistant on August 26, 2019 and was promoted to a counselor on May 28, 2020. Staff #8 holds a BA in Speech Communication, which does not meet the educational requirements for the position. In addition, staff #8 did not have any clinical experience documented at the time of hire and would need a full year of clinical experience prior to being promoted to counselor.
These findings were reviewed with facility staff during the licensing process.
This is repeat deficiency from the June 21, 2019 licensing inspection.
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Plan of Correction
The Facility Director will ensure that the qualifications for the position of counselor meets both the educational and experiential requirements for the position, including one year of clinical experience prior to being promoted to counselor. Staff #8 will be counselor assistant until the 1 year of clinical experience is met. |
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 staff training records, the facility failed to document HIV/AIDS and TB/STD training within one year of hire for counselors and counselor assistants in two of four records.
Staff #4 was hired as a counselor on November 5, 2018. TB/STD and HIV/AIDS training was due to be completed by November 5, 2019. There was no documentation of TB/STD and HIV/AIDS training in staff record #4.
Staff #6 was hired as a counselor assistant November 11, 2019. TB/STD and HIV/AIDS training was due to be completed by November 11, 2020. There was no documentation of TB/STD and HIV/AIDS training in staff record #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will ensure that counselors and counselor assistants will receive HIV/AIDS and TB/STD training within one year of hire.
Counselor assistants and counselors are required to complete the training in the first year. All other staff are required will receive HIV/AIDS AND TB/STD training within two years of hire. Training will now be done by the CRNP of NDHC and HIV Supervisor Training. Compliance to ensure training requirements are met will be done by the Facility Director and will be reviewed prior to the end of the calendar year for compliance. |