INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 11, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Good Works Life Recovery House 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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704.5(b) LICENSURE Clinical Supervisor
704.5. Qualifications for the positions of project director and facility director.
(b) If the facility does not have a clinical supervisor on staff, clinical responsibilities shall be addressed in one of the following ways:
(1) A facility director who has direct responsibility for clinical services shall meet the qualifications in at least one of the paragraphs of 704.7 (b) (relating to qualifications for the position of counselor).
(2) If the facility director does not meet counselor qualifications and the facility employs less than eight counselors, a lead counselor or part-time clinical supervisor shall be appointed.
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Observations
Based on a review of personnel records and an interview with the project/facility director, the facility failed to address clinical supervision responsibilities by employing a facility director that did not meet the qualifications for the position of counselor.Employee # 1 was promoted to the position of project/facility director on October 19, 2020 with an Associate degree in Human Services but did not meet the experiential qualifications for the position of counselor.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to the inspection, on December 8, 2020, the program director completed her bachelor's degree in human services. The degree with her experience now qualifies her to hold the position of counselor. The program director will ensure that any new staff meets the proper qualifications to hold the counseling position. This plan of correction is finalized on 2/18/2021. |
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to provide documentation that the project/facility director met the qualifications for the position.Employee # 1 was promoted to the position of project/facility director on October 19, 2020. Employee # 1 had an Associate degree in Human Services but did not have the required four years of experience in a human service agency.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to the inspection, on December 8, 2020, the program director completed her bachelor's degree program in human services. Her amount of experience and degree now qualifies her for the position of the program director. A copy of her degree can be found in her personnel file for future reference. The program director will ensure that any new staff meets the proper qualifications before they are hired onto the facility. This plan of correction is completed on 2/18/2021. |
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 provide documentation that each counselor met the qualifications for the position in two of two personnel records reviewed February 11, 2021.Employee # 1 was promoted to the position of counselor in March 2020. Employee # 1 had an Associate degree in Human Services but did not have the required two years of clinical experience.Employee # 2 was promoted to the position of counselor June 22, 2020. Employee # 1 had an Associate degree in Human and Social Services but did not have the required two years of clinical experience.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to the inspection, employee #1 received her bachelor's degree in human services and met the qualifications as a counselor. A copy of her degree can be found in her personnel file. Employee #2 was placed in the position of counselor assistant prior to the inspection. She will remain in this position until she completes her bachelor's degree. Weekly direct observation notes will be written on her for 9 months. The program director will approve when she is able to handle a full caseload. The program director will ensure that staff meets proper qualifications for a promotion before the promotion occurs. Any new staff will meet qualifications and experience before they are hired. This plan of correction is finalized on 2/18/2021. |
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 personnel/training records, the facility failed to document that staff persons received a minimum of 6 hours of HIV/AIDS training in one of three personnel/training records reviewed February 11, 2021.Employee # 3 is support staff and was hired August 8, 2018. There was no documentation of HIV/AIDS training for employee # 3.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #3 has registered for the Basic HIV virtual training on 4/5/21 and 4/6/21 through DDAP. Once she completes this training, a copy of the certificate will be available in her personnel file. From 4/6/21 on, human resources will check employee files to make sure all other non-clinical staff completes the 6-hour Basic HIV training within their first two years of employment. |
705.10 (b) (2) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(2) On floors with resident bedrooms, maintain a smoke detector which shall be located within 15 feet of each bedroom door. On floors with no resident bedrooms, the smoke detection device shall be located in a common area or hallway. All detection devices shall be interconnected.
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Observations
Based on a physical plant inspection conducted with the project/facility director on February 11, 2021 at approximately 1:30 PM, the facility failed to maintain smoke detectors that were interconnected between the first and second floors.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Office Administrator scheduled an appointment with a fire alarm company for 2/22/21 to come out to the facility and update the fire system. The company will interconnect the smoke detectors between the first and second floors and make sure the system is up to date. This plan of correction is finalized on 2/22/2021. |
705.10 (b) (4) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(4) Maintain a manual fire alarm system that is audible throughout the facility in a residential facility where four or more residents reside.
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Observations
Based on a physical plant inspection conducted with the project/facility director on February 11, 2021 at approximately 1:30 PM, the facility failed to maintain a manual fire alarm system on the first floor of the facility.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Office Administrator scheduled an appointment with a fire alarm company for 2/22/21 to come out to the facility and update the fire system. The company will update the fire system and install a manual fire alarm system on the first floor of the building. This plan of correction is finalized on 2/22/2021. |