INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on
April 13 -14, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Deerfield Center for Addictions Treatment 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 8, 2009.
|
Plan of Correction
|
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.
|
Observations
Based on a review of the personnel and training records and conversations with the Clinical Supervisor, the facility failed to ensure that a staff person met the qualification requirements for a counselor position.
The findings include:
A review of the personnel and training records occurred on April 13,2009 and conversations with the Clinical Supervisor occurred on April 13 -14, 2009. The counselor was hired in September 2006. She did not have the credentials to qualify for that position. Her Certified Addiction Counselor status had expired prior to her being hired. Although she has the required experience, she does not meet the educational requirements of the position. At the last survey, this was noted as a non-compliance. During the current survey, the facility failed to change the title to be a counselor assistant, and continued to list the staff member as a counselor This was documented via the counselor job description, the work performance evaluation completed in September 2008, and the listing on the facility summary report dated 4-13-09. Refer to personnel record #2.
|
Plan of Correction
The Clinical Supervisor will have the individual who does net meet the requirements for a counselor position will sign a new job description that designates her as a counselor assistant. This change in status will be resolved by May 1, 2009. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who 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.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
|
Observations
Based on a review of the personnel and training records and conversations with the Clinical Supervisor, the facility failed to provide documentation that a staff member who should be listed as a counselor assistant is working toward meeting the qualifications of counselor.
The findings include:
A review of the personnel and training records occurred on April 13,2009 and conversations with the Clinical Supervisor occurred on April 13 -14, 2009. The staff member, personnel record #2, failed to document that she is working towards counselor status. The staff member has an Associate Addictions Counselor 1 (AAC1). The staff member does not have a Bachelors degree which is now a requirement of the Pennsylvania Certification Board to obtain a full Certified Addiction Counselor (CAC). Therefore, the CAC which results from the AAC 1 is unobtainable.
|
Plan of Correction
The Program Director and the Clinical Supervisor will meet with the Counselor Assistant to establish a training plan that specifically speaks to the training steps this individaul will need to take to move from a counselor assistant to counselor position. A new development training plan will be established to assist this staff member to move from a counselor assistant to a counselor position over the remaining two years of the five year time requirement. This developmental training plan will be developed with the staff member, Program Director and the Clinical Supervisor over the next two weeks. |
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.
|
Observations
Based on a review of the personnel and training records and conversations with the Clinical Supervisor, the facility failed to provide documentation that a staff member completed the required hours of training for the 2007-2008 training year.
The findings include:
A review of the personnel and training records occurred on April 13,2009 and conversations with the Clinical Supervisor occurred on April 13 -14, 2009. The staff member, personnel record #2, failed to document the minimum number of training hours for the 2007-2008 training year. The staff member has 20 hours of training documented, and the requirement is 30 hours since she meets the qualifications as a counselor assistant.
|
Plan of Correction
The Program Director and Clinical Supervisor address this difficiency with the staff member are working with the individual to encure that she meets the educational requirements for a Counselor Assistant prosition. To date in fiscal year 2008-2009 she has attained 20 hours. She will have the required hours (30) by June 30, 2009. |