INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 6-7, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Consortium 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, the facility failed to ensure that each counselor met the qualifications for the position in one of three personnel records reviewed.
The findings include:
Five personnel records were reviewed August 6-7, 2013. Three personnel records were required to have documentation of the qualifications for the position of counselor.
Employee # 1 did not have a full year of experience prior to being promoted to the position of counselor on July 25, 2013.
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Plan of Correction
Responsible Party:
The Clinical Supervisor, HR Director, and Facility Director are responsible for ensuring that all Counselor Assistants meet the qualifications of full counselor, including previous experience for 1 full year, prior to being promoted to the position of full counselor.
Plan of Correction:
The Clinical Supervisor will provide documentation of close supervision for 6 months and direct supervision for one full year, on a weekly basis to ensure verification that requirements to meet full counselor status are met prior to submitting promotion of counselor status to the HR Dept.
Monitoring:
Facility Director will review weekly supervision status of counselor assistant, as well as the final review of recommendation for promotion of counselor assistant to ensure all requirements have been met prior to submitting to HR for change in status. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure that the counselor assistant counseled clients under the close supervision for at least the first six months in one of one personnel records.
The findings include:
Five personnel records were reviewed August 6-7, 2013. One personnel record was required to have documentation of six months close supervision.
Employee # 1 did not have documentation of close supervision prior to being promoted to the position of counselor on July 25, 2013.
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Plan of Correction
Responsible Party:
The Clinical Supervisor and Facility Director are responsible for ensuring that Counselor Assistant receive at least 6 months of documented close supervision.
Plan of Correction:
The Clinical Supervisor of Employee #1 will provide at least one hour per week of close supervision for a period of 6 months.
This close supervision will be documented on a clinical supervision note. If the Clinical Supervisor is out on a particular week, the supervision will take place with either another Clinical Supervisor, or the Facility Director.
Monitoring:
The Clinical Supervisor will send an electronic copy, or photocopied copy of the completed supervision note to the Facility Director each week to ensure that the weekly supervision is taking place as required. |
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 and training records, the facility failed to provide documentation of HIV/AIDS and TB/STD training in thirteen personnel and training records reviewed.
The findings include:
Personnel records were reviewed August 6-7, 2013.
Employee # 4 was hired July 19, 2011. This employee was required to obtain four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 5 was hired December 9, 2004. This employee was required to obtain four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 6 was hired May 15, 2008. This employee was required to obtain four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 7 was hired July 28, 1983. This employee was required to obtain four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 8 was hired December 8, 2008. This employee was required to obtain six hours of HIV/AIDS and four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 9 was hired May 28, 1996. This employee was required to obtain six hours of HIV/AIDS and four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 10 was hired April 15, 2007. This employee was required to obtain four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 11 was hired August 14, 2009. This employee was required to obtain four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 12 was hired September 1, 2009. This employee was required to obtain six hours of HIV/AIDS and four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 13 was hired September 14, 2009. This employee was required to obtain six hours of HIV/AIDS and four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 14 was hired September 14, 2009. This employee was required to obtain six hours of HIV/AIDS and four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 15 was hired September 14, 2009. This employee was required to obtain six hours of HIV/AIDS and four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
Employee # 16 was hired September 14, 2009. This employee was required to obtain four hours of TB/STD training, but failed to obtain the training as of the date of the inspection.
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Plan of Correction
Responsible Party: The Clinical Supervisors, Facility Director, Director of Training and HR Director are responsible for ensuring that Clinical Staff receive 4 hours of TB/STD and 6 hours of HIV/AIDS training within 1 year of employment and that all other support staff receive the same training within the first 2 years of employment.
Plan of Correction: Employees 4-16 will receive all required HIV/AIDS and
TB/STD training by 11/1/13.
The Training Director will provide the onsite HIV/AIDS and TB/STD trainings to ensure that all staff in need have an opportunity to receive these trainings by the identified deadline.
Monitoring: Supervisors will ensure that employees 4-15 are scheduled for the training prior to the identified deadline.
The agency will provide HIV/AIDS and TB/STD training on site at least once every 6 months to ensure all staff in need of the training, can receive it within the required timeframe. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical plant inspection, the facility failed to ensure that the hot water temperature did not exceed 120 Farenheit.
The findings include:
A physical plant inspection was conducted August 8, 2013. During the inspection of the newly renovated male and female restrooms on the first floor, it was determined that the water temperatures exceeded the required 120 Farenheit. Maintenance staff coordinating the inspection confirmed that those temperatures exceeded the required 120 Farenheit.
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Plan of Correction
Responsible Party: The Facilities Director/Staff are responsible for ensuring that the hot water temperature does not exceed 120 degrees Fahrenheit.
Plan of Correction:
The newly renovated male and female bathrooms had the hot water adjusted on August 9th to ensure that the temperature was under 120 degrees.
Monitoring:
The Facilities Dept. will conduct daily rounds to ensure the hot water temperature, in all bathrooms, including the newly renovated male and female bathrooms on the first floor, do not exceed the 120 degree Fahrenheit requirement.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to provide fire extinguisher training upon employment for two new staff.
The findings include:
Personnel records were reviewed August 6, 2013 for verification that staff had been instructed in the use of a fire extinguisher upon employment..
Two employees were hired since May 2013 and required fire extinguisher training upon hire. Training was documented as completed but not upon hire as designated by regulation.
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Plan of Correction
Responsible Party:
The Training and Licensing Director in conjunction with the Human Resource Director are responsible for ensuring that new hires are instructed in the use of the fire extinguisher upon staff employment and documentation of the training is filed in personnel records.
Plan of Correction: The two newly hired employees found not to be in compliance with this standard,will have documentation of fire extinguisher training in their personnel records by September 15, 2013.
Monitoring: The Human Resource Director will monitor personnel records on a monthly basis to ensure that the documentation of instruction in the use of the fire extinguisher and filing of the sign-off sheet for receiving fire extinguisher training.
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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 the review of personnel records, the facility failed to document emergency task performance training upon employment for two new staff.
The findings include:
Personnel records were reviewed August 6, 2013 for verification that staff had been instructed for emergency task performance upon employment..
Two employees were hired since May 2013 and required emergency task performance training upon hire. Both received the training but not upon hire as designated by regulation.
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Plan of Correction
Responsible Party: The Training and Licensing Director in conjunction with the Human Resource Director are responsible for ensuring that staff on all shifts is trained to perform assigned tasks during emergencies.
The Training and Licensing Director is responsible for providing Disaster training to all new hires to be completed within 7 days of hire and to ensure the filing of all verification of completed training in the personnel record.
Plan of Correction:
The two employees, found not to be in compliance with this standard, will receive Disaster Training on how to perform assigned tasks during emergencies by September 15, 2013.
Monitoring: The Human Resource Director will monitor personnel records of new hires for the documentation of emergency task performance training within 7 days of hire.
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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 project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility's administrative records were reviewed for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services on August 6, 2013. The facility's fiscal year runs from July 1 to June 30. The facility failed to provide documentation of an independent financial audit for the July 1, 2011 through June 30, 2012 fiscal year.
This is a repeat deficiency from the April 3, 2013 and November 16, 2012 licensure inspections.
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Plan of Correction
Responsible Party:
The Chief Financial Officer (CFO) is responsible for ensuring that the project's drug/alcohol abuse services has a completed financial statement and audit each fiscal year ending June 30.
Plan of Correction: The independent financial audit for the agency, including the project's drug/alcohol abuse services, for the July 1, 2011 through June 30, 2012 fiscal year, was completed and provided to the Facility Director on August 15, 2013.
Monitoring:
The CFO will coordinate and monitor the process of obtaining the services of an independent certified public accounting firm to perform the financial statement audit for the project's drug/alcohol abuse services for each fiscal year ending July 30th, by December 31st.
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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
Based on a review of client records, the facility failed to ensure a psychosocial evaluation was documented as required in eight of eight client records.
The findings include:
Eight client records were reviewed for psychosocial evaluations August 6-7, 2013.
Client record # 7 did not contain a documented psychosocial evaluation.
Client records # 1, 2, 3, 4, 5, 6 and 8 failed to evaluate and assess the historical data collected.
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Plan of Correction
Responsible Party: The Counselor of Record is responsible for completing a psychosocial evaluation within 30 days of the admission date of each client.
Plan of Correction:
Record # 7 will have a documented psychosocial evaluation completed by 9/15/13.
Records # 1, 2, 3, 4, 5, 6 and 8 will be updated to include an evaluation and assessment of the historical data collected by 9/15/13.
Monitoring: The Clinical Supervisor will review all new admission records to ensure that bio psycho social evaluations are completed fully and on time. This will be reviewed in bi-weekly supervision and documented on a supervision note.
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