INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 29, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc., West Chester 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 ensure that three of the six counselors employed at the facility met the qualifications for that position.The findings include:Employees # 2, 3 and 4 did not meet the qualifications for the position of counselor.Employee # 2 was hired a s a counselor on October 20, 2013. The facility failed to verify that the employee met the educational requirements for that position. The major course of study was not listed on the diploma and the facility was not able to produce any other documentation.Employee # 3 was hired on September 23, 2013. The facility failed to verify that the employee met the educational requirements for that position. The major course of study was not listed on the diploma and the facility was not able to produce any other documentation.Employee # 4 was hired on December 16, 2013. The facility failed to verify that the employee met the experiential requirements for that position. The employee had a qualifying graduate degree, but there was no documentation of clinical experience or a practicum in a health or human service agency.The findings were confirmed during an interview with the Human Resource Director and Human Resource Manager on April 18, 2014.
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Plan of Correction
The facility is now in possession of the documentation to verify that the employees # 2 and 4 listed in the citations are eligible to hold their respective positions.
Employee #2: In an effort to produce and verify the major course of study for this particular employee, Gaudenzia House West Chester obtained a transcript of this employee's undergraduate and graduate degree programs, which specified the major course of study for those degrees.
Employee #3: This employee was demoted due to not meeting criteria for F/T Counselor. This employee was demoted to a Counselor Assistant effective June 1, 2014.
Employee #4: In an effort to produce and verify that employee's graduate education and/or degree contained a practicum in a health or human service agency, Gaudenzia House West Chester obtained a transcript of this employee's graduate degree program, which specified the presence of a Human Services practicum.
In an attempt to eliminate reoccurrence of this citation, management/supervisory (Clinical/Program Supervisor, Administrative Coordinator) and the Program Director, who will be one that is the one who will be responsibile for overall compliance to screen resumes, degrees, and transcripts more thoroughly to ensure that candidate meet specified requirements and has the necessary supporting documentation, which specifies qualifications to include exact major courses/fields of study and practicum experiences.
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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 project's staffing requirements facility summary report (SRFSR), the project failed to ensure that all personnel received a minimum of 6 hours of HIV/AIDS and/or at least 4 hours of TB/STD and other health related topics training using a Department approved curriculum.The findings include:The facility failed to ensure that three of the employees completed the required training. Employee # 10 was hired as an intake specialist on March 14, 2011. This employee failed to complete the TB/STD and other communicable diseases training as of April 30, 2014.Employee # 11 was hired as a teacher on October 18, 1993. This employee failed to complete the HIV/AIDS and TB/STD and other communicable diseases training as of April 30, 2014.Employee # 12 was hired as a teacher on September 10, 2009. This employee failed to complete the HIV/AIDS and TB/STD and other communicable diseases training as of April 30, 2014.The findings were confirmed with the facility director on April 29 & 30, 2014.
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Plan of Correction
Employee #10: This individual is currently out on FMLA and is unable to attend any upcoming trainings until her return to work.
Employee #11: This individual has been scheduled to attend the next HIV/AIDS and TB/STD trainings. The next available HIV/AIDS training is scheduled on 9/5/2014. The next available TB/STD training is scheduled on 9/4/2014.
Employee #12: This individual has been scheduled to attend the next HIV/AIDS and TB/STD trainings. The next available HIV/AIDS training is scheduled on 9/5/2014. The next available TB/STD training is scheduled on 9/4/2014.
Program Director will be the identified employee that will ensure that Employees #11 and 12 attend the abovementioned training.
In an attempt to prevent the reoccurrence of this situation/deficiency, all facility staff, whether they are full/part-time will be scheduled for these trainings by Gaudenzia Training Institute. Oversight to ensure that this occurs will also take place at the facility, which will be the responsibility of Management Staff (Clinical/Program Supervisor, Administrative Coordinator.)
The Program Director will be the identified employee/person that will be one who is responsible to ensure overall compliance by ensuring that all staff of Gaudenzia House West Chester recieve the necessary trainings within the established guidelines.
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