INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 19-20, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Stepping Stones Unit @ Meadville Medical Center 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 the review of personnel records, the facility failed to ensure employees met the qualifications of a counselor in two of three personnel records.
Employee # 6 was hired as a counselor on May 24, 2021. The employee had eight months of clinical experience documented at the time of hire.
Employee # 7 was hired as a counselor on September 22, 2021. The employee had no documentation of clinical experience documented at the time of hire.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
#0037
Both candidates have been and are being supervised in all activities. Employee #6 has worked on this unit with mentoring and supervision by a CADC/CCS and the Clinical Supervisor since 5/24/21 as stated. He has satisfactorily completed the facility's orientation period for Substance Abuse Counselor and still has preceptor and Clinical Supervisor meeting with him weekly at minimum and in co-facilitating activities. He has at this time had the necessary experience. Future candidates will be questioned more thoroughly regarding exact previous duties and experience and also have former employers clarify via research of actual tasks and responsibilities of previous positions, as language in job descriptions vary from agency to agency.
Employee #7 will continue with orientation and preceptorship with additional formal documented supervision meetings added conducted by CADC/CCS and Program Clinical Supervisor. This employee shall be working under the title of Counselor Assistant until one year from hire date (9/22/2022) at which time he will be eligible to retain the title of Substance Abuse Counselor.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on the review of personnel records, the facility failed to ensure the project director completed at least 12 hours of annual training in one of one record.
Employee # 1 was hired by the facility on October 1, 2007 and was hired as the project director on September 9, 2017. The project director had only 1 hour of training documented for the January 1, 2020 to December 21, 2020 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
#0075
The Project Director described is also Meadville Medical Center's Chief Nurse Executive (a "Director of Nursing" Position) for the entire facility and all environs. Due to the continuation of the pandemic a new Project Director has been named to allow the Chief Nurse Executive to continue in her more urgent duties within the facility. The guidelines have been reviewed with the new Project Director, who is also the Meadville Medical Center Director of Quality Assurance. She is aware of the educational credit requirement and has had DDAP training access explained. She will acquire a minimum of 12 education credits annually. She will be taking that role effective immediately. |