INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clear Concepts Counseling 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 and a plan of correction is due on May 18, 2010.
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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 six personnel records on April 20, 2010, the facility failed to ensure that each counselor met the qualifications for the position in one of four personnel records. The findings include:In personnel record #3, the counselor did not meet qualifications for the position of counselor based on the fact that the counselor did not have the one year clinical experience.
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Plan of Correction
Our project is in full compliance with this standard as of today 4/21/2010. We mistakenly classified employee #3 as a counselor when in fact he is classified as a counselor assistant. This mistake was discovered during the on site licensure renewal inspection. In actuality, employee #3 will have direct supervision for 6 months during every session that is conducted a qualified staff memeber will be present and documentation will be completed. In the furture the Credentialing Coordinator is going to review every new hires credentials to ensure that they are classified for the correct position. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of facility staff CPR/first aid certification cards, the facility failed to ensure that at least one person trained in CPR/ first aid skills were onsite during the project's hours of operation. The findings include:Based on a review of staff schedules and staff CPR/first aid certification cards on April 23, 2010, the facility did not have sufficient staff trained in these skills on duty for the following shifts:The facility failed to have someone trained in First Aid on Monday, Tuesday, and Thursday from 4: 00 p.m. until 6:00 p.m. The facility failed to have someone trained in First Aid on Friday from 8:00 a.m. until 9:00 a.m. and 4:00 p.m. until 5:00 p.m.
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Plan of Correction
Our facility will be in full compliance with this regulation by 5/21/2010. We will have all staff trained in CPR and First Aid to cover all project hours of operations. In the future the Credenitaling Coordinator will have all new hires trained in CPR/First Aid within the first 90 days of employment. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the staffing self report form completed by the agency and employee records, the facility failed to ensure that staff to client ratios remained at or under 35:1.The findings included: During the review of the employee records on April 23, 2010, four clinical staff were reviewed. One employee was determined to be unqualified for their position, based on the documentation included in their records and, as a result, their clinical hours could not be counted in the client to staff ratios. Employee # 3 did not meet the qualifications to be a counselor. This employee was carrying a caseload of 32:1. The overall client to counselor ratio was 44:1 when employee #3 was not included in the ratio.
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Plan of Correction
Our facility will be in full compliance with this regulation by 5/10/2010. The number of clients assigned to employee #3 will be reduced in order to achieve the 35:1 client to counselor ration. The Clinical Supervisor will review this employees caseload on a regular basis during individual supervision to ensure this doesn't happen again in the future. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records on April 23, 2010 the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment. The findings include:Based on a review of seven client records, two records were required to have a notification of termination. The facility failed to notify one of two clients, specifically client # 7, as the facility involuntarily terminated the client's treatment on January 4, 2010 without notification of the specific reason for termination.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard will be reviewed with all counselors at our next staff meeting on 5/13/2010. The proper completion of client notification of termination will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor during individual supervision to assure compliance. In the future all therapists will bring their closed charts to supervision and the Clinical Supervisor will verify that the notification of termination is in the chart. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of client records, the facility failed to give the client an opportunity to request reconsideration of a decision terminating treatment. The findings include:Seven client records were reviewed on April 23, 2010. The project was required to give the client an opportunity to request reconsideration of a decision terminating treatment in one client record. The project did not document that client # 7 was given an opportunity to request reconsideration of the facility's decision to terminate the patient from treatment.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard will be reviewed with all counselors at our next staff meeting on 5/13/2010. The proper completion of informing the client they have the opportunity to request reconsideration of a decision terminating treatment will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance. In the future all therapists will bring their closed charts to supervision and the Clinical Supervisor will verify that the client had the opportunity to request reconsideration of their case being closed. |
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
Based on a review of client records and an interview with the clinical supervisor, the facility failed to document that an individual treatment and rehabilitation plan was developed with the client in six of seven client records.The findings included:Seven client records were reviewed on April 23, 2010. Six client records required the completion of an individual treatment and rehabilitation plan. The facility failed to document that an individual treatment and rehabilitation plan was developed with the client in client records #1, 2, 3, 4, 5, and 7. All treatment plans were documented in the file, however, it could not be determined whether or not the treatment plan was developed with the client. The treatment plan was not signed by the client, nor was there a progress note that indicated that the client had participated in the development of their treatment plan. The clinical supervisor confirmed that there was no signature space for the clients to sign the treatment plan.
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Plan of Correction
Our facility is in full compliance with this standard as of today 4/23/2010. This standard and our agency policy relative to this standard were reviewed immediately when it was brought to our attention during the on site licensure renewal inspection. We have added a client signature line to the treatment and rehabilitation services document to ensure the individual treatment and rehabilitation plan was developed with the client. In the future during Supervision the Clinical Supervisor will be visually verifying that all treatment plans are indeed signed by the client. |
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
Based on a review of client records and a staff interview, the facility failed to document follow-up attempts in one of the two required records. The findings include: Seven client records were reviewed on April 23, 2010. Two of the seven client records were required to document follow-up attempts. Follow up was not documented in one of two client records.Record # 7 was admitted on 10/1/2009 and discharged on 11/20/2009. According to facility policy, follow-up will be conducted 60 days after the client's closure date. The follow up attempt was due on 1/18/2010. As of the date of the inspection, follow-up had not documented for this client record. An interview with the project's clinical supervisor confirmed that follow-up was not conducted on this client.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard will be reviewed with all counselors and administration staff at our next staff meeting on 5/13/2010. The proper completion of a client follow up will begin immediately. This standard and policy will also be reviewed with all therapist by the Clinical Supervisor in individual supervision to assure compliance. In the future the Credentialing Coordinator will review on a regular basis that all follow up procedures are being conducted and proper documentation is being filed in the charts. |