INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Project Transition, Inc. 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the staffing requirements facility summary reports, the project failed to employ a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The staffing requirements facility summary reports for the project's five facilities were reviewed on September 6, 2013 as part of an administrative review. The project employed 10.3 full-time equivalent (FTE) counselors and/or counselor assistants as of September 6, 2013, which meant that it was required to employ at least one full-time clinical supervisor. However, as per the staffing requirements facility summary reports, the project failed to employ at least one full-time clinical supervisor.
The findings were forwarded to a project representative and were not disputed.
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Plan of Correction
Findings were reviewed with Senior Administration and a subsequent reorganization of duties was implemented to be effective 11/1/13. The CEO will assume Project Director Responsibilities. The VP's of Program Operations and of Quality have been re-assigned as Clinical Supervisors. A new Director of Quality/Licensing has been retained to start duties on 10/21/13.
Person Responsible: Project Director
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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 employee records, the facility failed to ensure that each counselor met the qualifications for the position in three of five employee records reviewed.
The finding include:
Five employee records requiring documentation of counselor qualifications were reviewed on September 6, 2013. The facility failed to ensure that counselors met the educational and/or experiential requirements for the position of counselor in employee records # 3, 4 and 5.
Employee # 3 was hired on June 17, 2013 as a counselor. The facility failed to demonstrate that employee # 3 met the educational and/or experiential requirements for the position of counselor.
Employee #4 was hired on December 28, 2012 as a counselor. The facility failed to demonstrate that employee # 4 met the experiential requirements for the position of counselor.
Employee #5 was hired on May 15, 2013 as a counselor. The facility failed to demonstrate that employee # 5 met the experiential requirements for the position of counselor.
The findings were forwarded to a project representative and were not disputed.
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Plan of Correction
Findings were reviewed with Facility and Project Directors. Employees for whom findings were noted have been immediately re-assigned to mental health program duties until the meet qualifications for the role of Counselor through either additional training or work experience. The Facility Director and Manager of Training and Education will complete a revised Staff Development Plan for each of these employees with a specific and time driven plan to achieve these qualifications with one year from 10/10/13 |
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
Based on a review of the facility's staffing requirements facility summary report, the facility failed to provide documentation of six hours of HIV/AIDS and/or at least four hours of TB/STD training for seven employees reviewed.
The findings include:
The facility's staffing requirements facility summary report was reviewed on September 6, 2013 as part of an administrative review. The facility failed to ensure that employees # 2, 3, 6, 8, 9, 10 and 11 received a minimum of six hours of HIV/AIDS and/or at least four hours of TB/STD training within the required time frame.
Employee # 2 was hired as a clinician on September 29, 2010, and was required to obtain six hours of HIV/AIDS training by September 29, 2011. The facility failed to ensure that employee # 2 received six hours of HIV/AIDS training as of the date of inspection.
Employee # 3 was hired as a clinician on June 1, 2009, and was required to obtain at least four hours of TB/STD training by June 1, 2010. The facility failed to ensure that employee # 3 received at least four hours of TB/STD training as of the date of inspection.
Employee # 6 was hired as a clinician on July 11, 2011, and was required to obtain six hours of HIV/AIDS and at least four hours of TB/STD training by July 11, 2012. The facility failed to ensure that employee # 6 obtained both trainings as of the date of the inspection.
Employee # 8 was hired as support staff on November 8, 2010, and was required to obtain six hours of HIV/AIDS and at least four hours of TB/STD training by November 8, 2012. The facility failed to ensure that employee # 8 obtained both trainings as of the date of the inspection.
Employee # 9 was hired as support staff on July 10, 2006, and was required to obtain six hours of HIV/AIDS and at least four hours of TB/STD training by July 10, 2008. The facility failed to ensure that employee # 9 obtained both trainings as of the date of the inspection.
Employee # 10 was hired as support staff on March 24, 2009, and was required to obtain six hours of HIV/AIDS and at least four hours of TB/STD training by March 24, 2011. The facility failed to ensure that employee # 10 obtained both trainings as of the date of the inspection.
Employee # 11 was hired as support staff on May 4, 2009 and was required to obtain 4 hrs of TB/STD training by May 4, 2011. The facility failed to ensure that employee # 11 received at least four hours of TB/STD training as of the date of inspection.
The findings were forwarded to a project representative and were not disputed.
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Plan of Correction
Findings were reviewed with Manager of Training and Education and Project Director. The Manager of Training and Education has identified HIV/AIDS and TB/STD trainings for all employees who have not received these trainings within the required time periods. These trainings will be completed by 12/15/13 under direct responsibility of the Manager of Training/Education. Additionally, a Human Resources Manager has been hired as of 10/1/13 to audit personnel/training files to ensure compliance for current and new employees |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the facility's fire drill record, the facility failed to ensure that fire drills were conducted at different times of the day during twelve of twelve months reviewed.
The findings include:
The facility's hours of operation are from 8:00 AM until 9:00 PM.
The fire drill record for the previous twelve months was reviewed on August 30, 2013. The facility failed to document fire drills between the hours of 2:30 PM.- 9:00 PM as all fire drills were documented before 2:30 PM.
The findings were forwarded to a project representative and were not disputed.
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Plan of Correction
Findings were reviewed with the Facility Director. Facility Director will immediately implement a rotating time of Fire Drills to encompass hours from 8am to 9pm. This will be verified through quality program audits every six weeks.
Person Responsible: Facility Director
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