INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 21 through August 24, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on September 22, 2006.
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Plan of Correction
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations did not address clients strengths, coping mechanisms, negative factors that may inhibit treatment or support systems in twelve of twelve client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12.
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Plan of Correction
Staff trainings and staff development articles will be provided regarding the documentation of clinical findings resulting from psychosocial evaluations. These assessments will address the individual's strengths, weaknesses, coping mechanisms and negative factors that may inhibit treatment or support systems. The Clinical Director will provide individual supervision and will monitor this area of content. Random, monthly chart audits by the Executive Director will ensure compliance. |
709.92(a) 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:
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Observations
Treatment plans were not individualized to meet client needs in twelve of twelve records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12.
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Plan of Correction
Staff trainings and staff development articles will be provided emphasizing the need for individualized treatment plans. Twice weekly clinical team meetings, individual supervision by the Clinical Director and random, monthly chart audits by the Executive Director will ensure compliance. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The frequency of services were not documented on treatment plans in twelve of twelve client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12.
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Plan of Correction
Staff training and staff development articles will be provided regarding the documentation of frequency of services on treatment plans. Twice weekly clinical team meetings, individual supervision by the Clinical Director and random, monthly chart audits by the Executive Director will ensure compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Treatment plans updates did not address the client's progress related to previously stated treatment plan goals in twelve of twelve client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12.
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Plan of Correction
Staff training and staff development articles will be provided regarding the documentation of client's progress or lack of progress as it relates to previously stated treatment plan goals. Twice weekly clinical team meetings, individual supervision by the Clinical Director and random, monthly chart audits by the Executive Director will ensure compliance. |
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
Employee #2 did not meet the educational requirements for the position of counselor.
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Plan of Correction
Employee #2 will assume the position of Treatment Specialist Trainee as outlined in the Treatment Specialist Trainee Job Description. Documentation from her former employer will be obtained which documents her receiving direct supervision for 3 months and close supervision for 9 months while providing counseling services. The Clinical Director of The Open Door will provide a written positive assessment of the employee's clinical skills based on his observations of her counseling skills.
Employee #2 will begin the process of attaining her C.A.C.
The documentation from her former employer and the positive assessment from the current Clinical Director will be mailed hard copy to the PA Department of Health, Division of Drug and Alcohol Program Licensure.
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