INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 7-8, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Crossroads Counseling 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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709.83(a) LICENSURE Client records
709.83. 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:
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Observations
Six client records were reviewed for the partial hospitalization activity on March 8, 2017. The facility failed to document a complete client record in client records # 12, 13, 14, 15, and 16.
Client # 12 was admitted into treatment on 1/26/17 and was still active in treatment. The record of service documented in the client's record indicated that the client attended a group counseling session on 2/17/17. The service provider and the duration of service for this counseling session was not documented on the record of service. The record of service also indicated that the client attended a group counseling session on 2/24/17. The duration of service for this counseling session was not documented on the record of service.
Client # 13 was admitted into treatment on 12/30/16 and was still active in treatment. A progress note documented in the client's record indicated that the client attended an individual counseling session on 1/13/17. This counseling session was not documented on the client's record of service.
Client # 14 was admitted into treatment on 2/14/17 and was still active in treatment. A progress note documented in the client's record indicated that the client attended a group counseling session on 2/17/17. The progress note indicated that duration of this counseling session was 3.5 hours. However, the client's record of service indicated that the duration of service for the counseling session was 4 hours. In addition, another progress note documented in the client's record indicated that the client attended a group counseling session on 2/24/17. The progress note indicated that the duration of this counseling session was 3.5 hours. However, the client's record of service indicated that the duration of service for the counseling session was 4 hours.
Client # 15 was admitted into treatment on 2/17/17 and was discharged on 2/27/17. A discharge summary was not documented in the client's record.
Client # 16 was admitted into treatment on 2/13/17 and was discharged on 2/16/17. A discharge summary was not documented in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all requirements regarding having a complete client record. Clinical supervisors and staff have been trained by the Clinical Director on the proper completion of a record log and reminded that all services need to be included in the record of service with special emphasis on including the date and duration of the service. Additionally clinical supervisors and staff have been trained by the Clinical Director on the proper completion of a discharge summary. Client records # 15 and 16 have had discharge summaries completed to correct the deficiency.
Clinical supervisors will randomly audit files on a weekly basis to assure that all record keeping requirements are being kept. Clinical director will follow up monthly with clinical supervisors to assure continue compliance.
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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
Fifteen staffing records were reviewed for the Counselor position on March 7-8, 2017.
Employee # 8 was hired as a counselor on 4/6/16. The qualifications documented in the employee's record indicated that the employee completed a Bachelors's degree in Psychology. Documention of the employee's prior work experience failed to demonstrate that the employee acquired at least 1 year of prior clinical experience. Therefore, employee # 8 did not meet the qualifications for the position of Counselor.
Employee # 22 was hired as a counselor on 3/8/16. The qualifications documented in the employee's record indicated that the employee completed a Bachelor's degree in Psychology. Documentation of the employee's prior work experience failed to demonstrate that the employee acquired at least 1 year of prior clinical experience.
These findings was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all requirements regarding counselor qualifications.
In regards to Employee #8, the employee was supervised as a counselor assistant from the time of hire and these supervision notes have been submitted and reviewed by licensing. Executive Director will be responsible for completion of future staffing reports and will ensure that all employees are placed into the proper positions and properly identified on the staffing form.
In regards to Employee # 22, the employee came to us with several years of past experience. Upon review with licensing, we now understand that their past experience has been determined to be non-clinical thereby making this employee a counselor assistant instead of a counselor. Effective 3/27/17 we increased employee 22's supervision to the level consistent for a counselor assistant and will continue to do so until they have sufficient clinical experience to become a counselor. Director will be responsible to approve future hires and review resumes thoroughly to assure appropriate classification and supervision of new staff.
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