INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 20 and April 21, 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 seven personnel records on April 20, 2010, the facility failed to ensure that each counselor met the qualifications for the position in one of four records.Findings:In personnel record #5, the counselor did not meet the qualifications for the position of counselor based on the fact that the counselor did not have one year of 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 #5 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 #5 will have direct supervision for 6 months during every session that is conducted a qualified staff member will be present and documentation will be completed. In the future 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 and 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 21, 2010, the facility did not have coverage during the following hours of operation:Monday evening there was no CPR of First Aid coverage from 6:00 p.m. until 9:00 p.m. Tuesday evening there was no CPR or First Aid coverage from 7:30 p.m. until 9:00 p.m. Wednesday evening there was no First Aid coverage from 6:00 p.m. until 6:30 p.m. Additionally, there is no CPR Coverage from 5:00 p.m. until 7:00 p.m.Thursday evening there was no CPR/ First Aid coverage from 7:30 p.m. until 9:00 p.m.
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Plan of Correction
Our facility will be in full compliance with this regulation by 5/31/10. We willhave all staff trained in CPR and First Aid to cover all project hours of operations. In the future the Credentialing Coordinator will have all new hires trained in CPR/First Aid within the first 90 days of employment. |
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.
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Observations
Based on a review of personnel records and staff interview, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of two personnel records reviewed.The findings include:Seven personnel records were reviewed on April 20, 2010. Four personnel records were counselors. Two personnel records were required to document the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record #4.Employee # 4 was hired on February 7, 2002. The facility training year is from July 1, 2008 through June 30, 2009. Employee # 4 only had 12 documented clock hours of annual training for the 2008/2009 training year. The clinical supervisor confirmed that employee #4 did not obtain the 25 hours of required annual training.
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Plan of Correction
Our facility will be in full compliance with this standard by 06/30/2010, which is the end of our current training year. By that date each employee will have received 25 training hours as is required by the standard. Employee #4 had failed to complete the required trainings. This employee will seek out & attend trainings throughout the year, which will address the areas set forth by the standard. The Clinical Supervisor is responsible for ensuring the corrective action(s) is implemented. In the future, the Credentialing Coordinator will conduct quarterly reviews of all training hours to ensure that this standard is being complied with. |
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 sixteen of sixteen client records.The findings included:Sixteen client records were reviewed on April 21, 2010. Sixteen 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, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16. All treatment plans were documented in the client records, however, there was no way to determine 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 the client had participated in the development of the treatment plan. The Clinical Supervisor confirmed that the clients had not signed their treatment plans.
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Plan of Correction
Our facility is in full compliance with this standard as of today 4/21/2010. 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 signeed by the client. |