INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on April 21, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Pennsylvania Adult & Teen Challenge 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records on April 21, 2020, it was discovered that the facility could not verify Employee #11's Bachelor's degree as of the date of the inspection. Due to the degree not being authenticated, Employee #11 does not meet the requirements for the position of counselor of which they were hired for on August 12, 2019.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Action has been taken to verify counselors degree. Until such time that degree can be verified, counselor will not act as a counselor or carry a caseload. Facility reached out to school to receive verification of degree. Completed counseling with Human Resources staff on April 20, 2020 that this step must be completed prior to staff hire in order to remain in compliance. Human Resources staff confirmed that all future hires will follow policy and verify qualifications prior to hire. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form on April 21, 2020, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employees #7 and 10 employee's record. The facility's training year that was reviewed was from January 1, 2019 through December 31, 2019.
Employee #7 was hired as a counselor on August 23, 2017 and was still in the position as of the date of the Part 1 inspection. Employee #7's employee record only documented 24 hours of annual training for the training year reviewed.
Employee #10 was hired as a counselor on May 25, 2017 and was still in the position as of the date of the Part 1 inspection. Employee #10's employee record only documented 23 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical Supervisor has begun tracking training hours for all counselors beginning January 2020, and will ensure all staff follow up with counseling hours throughout the year. Part of this deficiency is due to a missed internal training at the facility during calendar year 2019. Follow up with training department on 4/20/2020 ensured that no training will be missed for calendar year 2020. PA Adult and Teen Challenge has implemented an online training platform starting April 22, 2020, which will allow all staff to complete training throughout the year, and supervisors to follow up on missed training. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
A review of the August 2019 through March 2020 fire drill logs was conducted during the Part 1 inspection on April 21, 2020. The fire drill logs for August 2, 2019 and March 31, 2020 failed to include the exit route used.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Fire drill log was reviewed and corrected. Training completed with fire marshal on April 23, 2020 to include this information on all fire drill logs.
Reviewed policy outlining proper fire drill procedures and documentation. |