INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8-9, 2019 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, Family Services of Warren County, Inc 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 that counselors met the qualifications for the position in one of three records. Seven personnel records were reviewed on April 8-9, 2019. Three were reviewed as new hires. Personnel record # 7 did not meet the requirements for the position of a counselor upon hire. Employee # 7 was hired on July 3, 2017 as a counselor. As the facility was approved for a bi annual inspection for the year 2018, the employees qualification were reviewed on April 8-9, 2019. At the time of the employee's hire, there was no documentation of the 1 year of experience. The employee had only 2 months of job shadowing documented at the time of hire. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director/Project Director prior to hiring new employee's for the position of counselor and/or counselor assistant in the drug and alcohol program will review regulation 704.7 and 704.8. The Facility Director/Project Director will ensure that the candidate for employment has met the qualifications indicated in regulation 704.7 and 704.8 prior to any offer of employment. Implementation will start 4-18-19. |
709.26 (a) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(3) Supervision of staff.
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Observations
The facility failed to document policies that included the supervision of staff. The policy and procedure manual was reviewed on April 8-9, 2019. There was no policy documented addressing the supervision of staff. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director/Project Director will establish a Policy and Procedure that addresses regulation 709.26 Personnel Management. Specifically, staff will meet with the Project Director weekly to biweekly depending on clinical experience/needs for supervision of staff. Implementation of this policy and procedure will take place on 4-18-19. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
The facility failed to obtain an informed and voluntary consent for the client in two of seven records reviewed. Seven client records were reviewed on April 8-9, 2019. All required consents to release information. Client records # 1 and 3 were missing consents to release information for the client's funding source. These findings were reviewed with facility staff duing the licensing process.
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Plan of Correction
Support staff will obtain an informed voluntary consent to release information to the funding source for billing purposes at the time the client checks in at the first encounter. The primary counselor will be responsible to ensure the release of information is completed and complies with 255.5. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to obtain an informed and voluntary consent that included the specific information to be disclosed, in five of seven client records. Seven client records were reviewed on April 8-9, 2019. All required consents to release information. Client records # 1, 2, 4 and 7 documented releases which listed "d&a information" as the specific information to be released. No specific information to be release was documented. Client record # 6 documented a release of information that was missing documentation of the information to be released. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director/Project Director will develop a new release of information that includes whether a client is or is not in treatment/attendance, general description of clients progress related to recovery, brief statement regarding relapse and frequency of relapse, clients prognosis/diagnosis, and nature of the project. Any other information that does not apply to 255.5 will specifically be stated on the release of information. The Facility Director/Project Director will hold an in house training on how to complete the new release of information on 4/24/19. An internal audit will be completed by the project director for one month after the implementation of the revised release of information. All new employees will receive training on how to complete the document appropriately. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
The facility failed to develop an individual treatment and rehabilitation plan that included long term goals in seven of seven client records. Seven client records were reviewed on April 8-9, 2019. All required documentation of a treatment and rehabilitation plan. Client records # 1, 2, 3, 4, 5, 6 and 7 did not document long term goals on the individual treatment and rehabilitation. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director has established a revised treatment plan form that includes a long term goal section. Staff will be trained on implementation of this revised treatment plan form on 4-24-19. All staff are required to use the revised treatment plan form effective 4-24-19. The Project Director will complete an internal audit for one month after the implementation date of 4-24-19 to ensure compliance. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
The facility failed to develop an individual treatment and rehabilitation plan that included support services in five of seven client records. Seven client records were reviewed on April 8-9, 2019. All required documentation of a treatment and rehabilitation plan. Client records # 1, 2, 4, 6 and 7 did not document support services on the individual treatment and rehabilitation. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director has established a revised treatment plan form that includes a support services section. Staff will be trained on implementation of this revised treatment plan form on 4-24-19. All staff are required to use the revised treatment plan form effective 4-24-19. The Project Director will complete an internal audit for one month after the implementation date of 4-24-19 to ensure compliance. |