INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 15, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Diakon Child, Family and Community Ministries 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 a review of personnel records, the facility failed to document that each counselor met both the education and experiential qualifications for the position.
Employee #4, who was hired as a counselor on July 25, 2022, did not meet the experience requirements to be a counselor. At the time of hire, the employee did not have one year of clinical experience required to be a counselor with a bachelor's degree.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director and employee #4 met 7/12/23. The employee will only counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least 6 months of employment. The Clinical Director and/or Facility Director will continue to provide employee #4 with weekly supervision until she meets the requirements of 704.7B. The Clinical Director and Facility Director will monitor for supervision requirements and staffing needs. The Clinical Director and facility Director will monitor necessary trainings on a quarterly basis and follow up with staff with outstanding trainings. Employee #4 shall document to the Clinical Director and Facility Director that she is working toward counselor status. This information shall be documented in her file. Moving forward, the facility will utilize the role of counselor assistant for staff members not meeting regulatory requirements for experience. When employee #4 satisfactorily completes one of the sets of qualifications in § 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of four applicable records reviewed.
Client #2 was admitted on September 30, 2022 and was still active at the time of the inspection. A treatment plan update was completed on March 7, 2023 and the next update was due no later than May 7, 2023; however, the next update was completed on May 16, 2023.
Client #3 was admitted on April 4, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on April 11, 2023 and the update was due no later than June 11, 2023; however, none was completed.
Client #4 was admitted on December 13, 2022 and was still active at the time of the inspection. A treatment plan update was completed on February 28, 2023 and the next update was due no later than April 28, 2023; however, the next update was competed on May 2, 2023.
Client #6 was admitted on September 13, 2022 and was discharged on February 3, 2023. A treatment plan update was completed on September 13, 2022 and the next update was due no later than November 13, 2022; however, none was competed.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 22, 2022 licensing inspection.
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Plan of Correction
The clinical staff will assure treatment and rehabilitation plans shall be reviewed and updated at least every 60 days per Diakon Family Life Service's policy. If the client is not present for the review/development of a treatment plan review the clinical staff will develop the treatment plan update and review with client at next attended session. This will be in compliance effective 7/28/2023. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Director through staff meetings, staff training, quality reviews and supervision. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in two out of five applicable records reviewed. The facility's policy and procedures manual states that case consultations are completed every 90 days for the first year than annually thereafter.
Client #4 was admitted on December 13, 2022 and was still active at the time of the inspection. There was one case consultation documented in the client record on February 28, 2023.
Client #6 was admitted on admitted on September 13, 2022 and discharged on February 3, 2023. A case consultation was completed on September 13, 2022 and the next one was due no later than December 13, 2022; however, it was not completed until February 3, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical staff will assure case consultations shall be completed every 90 days following admission, according to Diakon policy. This will be in compliance effective 7/28/2023. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Director through staff meetings, staff training, quality reviews and supervision. |