INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 6 - 7, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, George Junior Republic 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 four personnel records.
The findings include:
Six personnel records were reviewed on January 6, 2016. One personnel record was reviewed as a new counselor and required qualifying documentation for the position of counselor. The facility failed to provide documentation of required qualifications in personnel record # 6.
Employee # 6 was hired as a counselor on November 11, 2015. Based on the review of the personnel record, the employee did not meet either the educational nor the experience requirements for a counselor position. The employee received an Associates Degree in Applied Science with the major listed as Social Service Technology. This is not a qualifying degree. There was no documentation provided that the employee had the required clinical experience in a health or human agency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 1/7/2016, Employee #6 was removed from a Counselor position by the Facility Director. Employee #6 will remain on the employee roster as a direct care worker and will not initiate treatment.
Effective immediately, The Project Director and Facility Director will review all applicants for the counselor position to ensure the applicant meets qualifications for the position of counselor. |
705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical plant inspection, the residential facility failed to maintain portable fire extinguishers, with a minimum of an ABC rating, where additional fire extinguishers were required for each additional 2000 square feet or fraction thereof of floor space.
The finding include:
A physical plant inspection of the three drug and alcohol licensed residential facilities was conducted on January 7, 2016. Each residential facility was greater than 5000 square feet and required at the minimum of 3 ABC rated fire extinguishers. The required number of ABC rated fire extinguishers were not maintained at the three residences.
Facility W had 5433 square feet of floor space and required 3 ABC rated fire extinguishers. The facility had one ABC rated fire extinguisher. The remaining two fire extinguishers were labeled "Water" and were not labeled as ABC rated.
Facility P had 5468 square feet of floor space and required 3 ABC rated fire extinguishers. The facility had two ABC rated fire extinguishers. The remaining two fire extinguishers were labeled "Water" and were not labeled as ABC rated.
Facility M had 5,927 square feet of floor space and required 3 ABC rated fire extinguishers. The facility had one ABC rated fire extinguisher. The remaining three fire extinguishers were labeled "Water" and were not labeled as ABC rated.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director contacted the Plant Manager in writing and the Facility Director will ensure that 1 ABC rated fire extinguisher for each 2000 square feet will be stationed in Facility W, Facility Prasse and Facility Memorial by January 28, 2016. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on the review of client records, the facility failed to document efforts towards informing clients of their rights that included: the project, facility or clinical director may temporarily remove potions of the records prior to the inspection of the client if the director determines that the information may be detrimental if presented to the client; that the client has a right to appeal a decision limiting access to their records; that the client has a right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in eight of ten client records.
The findings include:
Ten client records were reviewed on January 6, 2016. Ten client records were reviewed for documentation that clients were informed of their rights. The facility did not document that the client was informed of the above mentioned rights in client records # 1, 2, 3, 4, 5, 6, 7 and 8.
Client # 1 was admitted on August 29, 2015. There was no documentation provided that the client was informed of the above mentioned rights.
Client # 2 was admitted on September 2, 2015. There was no documentation provided that the client was informed of the above mentioned rights.
Client # 3 was admitted on July 30, 2015. There was no documentation provided that the client was informed of the above mentioned rights.
Client # 4 was admitted on September 24, 2015. There was no documentation provided that the client was informed of the above mentioned rights.
Client # 5 was admitted on November 21, 2015. There was no documentation provided that the client was informed of the above mentioned rights.
Client # 6 was admitted on March 24, 2015 and discharged on November 4, 2015. There was no documentation provided that the client was informed of the above mentioned rights.
Client # 7 was admitted on May 19, 2015 and discharged on August 11, 2015. There was no documentation provided that the client was informed of the above mentioned rights.
Client # 8 was admitted on March 3, 2015 and discharged on September 3, 2015. There was no documentation provided that the client was informed of the above mentioned rights.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will ensure that current clients of the client records reviewed, and all applicable records of current clients are amended to document that the client was informed of their rights that included: The project, facility, or clinical director may temporarily remove portions of the records prior to the inspection of the client if the director determines that the information may be detrimental if presented to the client; that the client has a right to appeal a decision limiting access to their records; that the client has a right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records. All applicable records were amended by Thursday, January 28, 2016. The Facility Director will ensure that the Confidentiality Packet is accurate and password protected. The Facility Director must approve any corrections or changes. |