INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the April 17, 2009 licensure renewal inspection. The follow-up inspection was conducted on September 29, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 October 23, 2009.
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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 follow-up telephone conversation with the clinical supervisor and the subsequent information regarding credentials and training that was faxed to the Division, the facility failed to ensure that an employee met the qualification requirements for a counselor position.
The findings include:
A telephone follow-up inspection was conducted on September 29, 2009. Employee # could not produce the minimum qualifying credentials for the position of counselor. The facility continued to employee this individual in a counseling position. This was confirmed by the clinical supervisor at the time of the telephone call. The Department approved plan of correction indicated that this would be in compliance as of May 1, 2009.
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Plan of Correction
The employee referred to in observation #0037 has a signed job description recognizing her as a conselor assistant as of 4/27/09. |
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.
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Observations
Based on a follow up telephone conversation with the clinical supervisor, employee # 2 has not provided any documentation to demonstrate that he/she is working toward counselor status.
The findings include:
The plan of correction follow up inspection was conducted on 9/29/09 with the clinical supervisor. The clinical supervisor was not able to provide any documentation to demonstrate the employee # 2 was working toward the minimal qualifications for the position of counselor. The plan of correction approved by the Department stated that this would be in compliance by May 11, 2009.
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Plan of Correction
As the Program Director, I helped to develop a new Training Development Plan for employee #2. with the intent to help her meet the qualifications to meet the requirements of a Counselor. This new plan was signed by employee #2 on May 18, 2009. |
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.
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Observations
Based on a plan of correction follow up inspection conducted by telephone with the clinical supervisor, the facility failed to ensure that a clinical employee who met the requirements for a counselor assistant position obtained at least 30 hours of training during the second and subsequent years.
The findings include:
The plan of correction follow up inspection was conducted by telephone on September 29, 2009 with the clinical supervisor. The interview with the clinical supervisor and a review of material faxed to the office by the clinical supervisor on 9/29/09, revealed that employee # 2 had only obtained 28 hours of training for the 2009-2009 training year. The approved plan of correction indicted that this would be corrected as of June 30, 2009.
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Plan of Correction
The Program Director and the Clinical Supervisor reviewed employee #2's training book. It was found that she had in excess of 30 training hours. However, on the Training Year Assessment form for Fiscal Year 2008-2009 it only showed 28 hours of training. The Clinical Supervisor will review the Training files of all clinical staff to insure that they are accurate. This will be completed over the next two weeks. |