INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 22, 2007 through March 23, 2007 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 April 19, 2007.
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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
Employee # 5 does not meet the experiential requirements for a counselor.
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Plan of Correction
Counselor in question signed a new job description with a new title and clear specifications as to need for close supervision. This counselor assistant will receive weekly one hour per week supervision to adress all aspects of daily responsibilities to include intakes, individual sessions, and the facilitation of group treatment. The clinical supervisor will keep written recordes ot topics covered as well as assignments to further the professional growth and development of the counselor assistant. The weekly three hour staff meeting that occurs with both the program director and clinical supervisor present will supplement the weekly clinical supervision, as client progress and difficulties are addressed while giving direction on client treatment planning. All staff are a part of this process. This level of supervision will be ongoing, as it is already part of our way of supervising staff. The counselor assistant will also participate in an individualized training plan that will include all mandatory training as well as other counseling competencies that are towards the goal of becoming a Certified Addictions Counselor. |
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
The supervision notes for employee # 11 were not completed on a weekly basis as required for close supervision.
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Plan of Correction
Counselor assistant in question will receive weekly supervision with the clinical supervisor and this session will be documented. An hour has been reserved weekly until this intern has completed her course of study in May 2007. The intern's learning agreement was accepted as her individualized training plan. |
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
The procedures for the creation of the program's overall training plan, annual evaluation of prior year's training plan, and the assessment of staff training needs were not congruent with the current practice of the program.
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Plan of Correction
The agency's 704.11 (a) 1-4 written standards did not clearly define the staff development program in current practice. The overall Training Plan for the agency's programs did not specifically list action plans for trainings needed and planned for the training year. All agency programs are currently in full compliance. The next revised Training Plan will be submitted by October 2007. The agency's spring brochure, indicating specific scheduled trainings, will serve as the current training plan until the end of the fiscal/training year (June 30, 2007). The agency's 704.11 (a) 1-4 were written and approved by Treatment Trends, Inc. administration and DDAPL evaluator on 03/21/07. They more clearly define current procedures for assessment of staff training needs, the development of the Training Plan, feedback on training, and annual evaluation of previous year's training. The Training Coordinator has been informed of the revised procedure and content for the yearly overall Training (action) Plan. The new 2007/08 Training Plan will be developed by the Training Coordinator during July 07 thru Sept. 07 (with input from the Training Planning Committee - who have analyzed staff training needs and feedback from prior year's training). The Training Plan will be submitted by October 2007 for immediate implementation. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The individual training plans were not completed within the 30 days of the employee's hire date, as per the program's policy, for employee # 5, 7, 8, and 9.
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Plan of Correction
The revised New Employee Training Plan will be put into use immediately, as of March 26, 2007 and indicated in the revised policies for our agency. Missing Training Plans for employees #5,7,8,and 9 have been completed and put in their personnel files as of March 30, 2007. To make sure initial training plans are done with new hires within 30 days, the New Employee Training Plan, standard 704.11 (b)(1), and procedure has been revised. The New Employee Training Plan form now includes a top section that is an initial training plan to be filled out on the date of hire with new hire paperwork. The Training Coordinator will assist the employee in filling in required trainings needed in the first year of employment for that employee's position. This will be signed by the employee's supervisor and filled within 30 days. The Training Coordinator will assure completion and supervisor signature on the top/initial section. When orientation checklist is completed, the rest of the New Employee Training Plan (bottom section) will be done with the Supervisor and training goals more specifically recommended by the supervisor will be put in this section. The fully completed New Employee Training Plan will then be filed in the employee's personnel folder. Supervisors and Training Coordinator will track to be sure these are completed. |
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
Employee # 8 does not have the mandatory TB/STD training.
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Plan of Correction
Deficient employee is registered to attend the required TB/STD training on April 23, 2007. Other staff who have yet to receive this training are registered for this same date. |
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 treatment plans did not contain measurable action steps in three of eight client records reviewed, # 1, 2, and 5. The treatment plan was missing in one of eight client records reviewed, # 6.
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Plan of Correction
Each clinical staff member will have a treatment plan review with their supervisor in individual supervision before April 21, 2007. All staff will be required to attend a one hour in-service training on May 3, 2007 at 1 PM to review the expectations for an adequate treatment plan with particular attention to making objectives and action steps measurable and goal supportive. The program director and the clinical supervisor will alternate each month the supervisory responsibility of the clinical review of all client treatment plans. Monthly audits will be scheduled by the clinical supervisor to review files and treatment plans will be a part of this audit. |
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
The treatment plan updates did not provide a review of progress on all previously stated goals in three of seven client records reviewed, # 2, 3, and 4. Treatment plan updates were either missing or completed later than the required 60 days in five of seven client records reviewed, # 1, 3, 5, 7, and 8.
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Plan of Correction
Each clinical staff member will have a treatment plan review with their supervisor in individual supervision before April 21, 2007. The focus will be on the timeliness of treatment plan completions by problem solving about how to organize and anticipate due dates of such plans. Discussion will be on a better review of past goals and why a client "completed", "partially completed", or "failed to complete" their goals. All staff will attend a one-hour in-service training on May 3, 2007 at 1 PM given by the clinical supervisor to review these standards and expectations for treatment planning with clients. Monthly audits will be scheduled by the clinical supervisor to review files and treatment plan reviews are a part of this audit. |
709.93(a) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
The DUI client records, where treatment is to be provided, are not complete as per the requirements of the outpatient standards on client records.
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Plan of Correction
All DUI clients receiving treatment shall comply with all applicable BDAP standards. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
The case consultations were missing at 90-day intervals as per the program's policy in four of eight client records reviewed, # 1, 3, 7, and 8.
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Plan of Correction
Case consultations will be discussed, reviewed, and completed in weekly supervision if they have not already been completed by the due date. Any overdue paperwork will be compiled by the administrative staff and distributed to all counselors' as well as supervisory staff for review and completion within 2 weeks of the due date. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
The aftercare plans were missing in two of three client records reviewed, # 12 and 16.
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Plan of Correction
The importance of client aftercare plans will be emphasized in counselor supervision individually as well as be discussed at the weekly staff meeting on or before April 10, 2007. Counselors will be informed that no client file can be closed until an aftercare plan is completed with the client. In situations that this is not possible, a note will be made on the aftercare plan form explaining the counselor's inability to complete the document. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Discharge summaries were missing in three of eight client records reviewed, # 12, 13, and 14.
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Plan of Correction
The importance of discharge summaries will be discussed in counselor supervision and reviewed to ensure a high standard of completion. Counselors will address in their weekly staff meeting that no client file will be closed until a discharge summary is completed. In the case where a counselor is unable to complete a discharge summary for any reason, the program director or clinical supervisor will complete the summary based on the counselor's notes. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Follow-up information was not documented in five of six client records reviewed, # 9, 10, 12, 15, and 16.
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Plan of Correction
A new form was developed and will be implemented on April 3, 2007. Every counselor will receive a packet of these follow-up forms and has the responsibility to make a follow-up attempt within a week of their client's discharge from the program. The form includes documenting the outcome of the follow-up attempt and will be signed and dated. No client file will be completed and "closed" post-discharge until the program director or clinical supervisor reviews to see if both a discharge summary and follow-up documentation were completed. |