INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 28-31, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Penial Drug and Alcohol Residential Treatment Facility 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 September 1, 2008.
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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 the review of eleven personnel records, four of which were reviewed as counselor positions, the facility failed to document the qualifications of a counselor in one record, #5. The counselor's major was Criminology and she had less than one year of experience. Documentation of the counselor's qualifications need to be submitted to the division.
Based on a review of personnel records and conversation with the acting project/facility director it was determined that the facility failed to insure that the staff person appointed to the acting project/facility director position met the appropriate educational requirements.
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Plan of Correction
The Director of Peniel called the director of this staff's former employer requesting verification of her counseling experience qualifications which was then immediately faxed to Peniel. Along with the letter from the former employer, we enclosed copies of her transcripts and immediately forwarded them to your office. We were informed (by phone) that this information is under review and we are presently awaiting a decision.
Notwithstanding, this staff member's resume has been updated and her job description has been changed to be a Counselor Assistant until a determination has been made.
Plan of Correction Timeframe:
IMMEDIATELY |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on the review of the annual report for 2007, the facility failed to make available to the public an annual report that included a financial statement of income and expenses. No financial statement of income and expenses was included in the annual report.
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Plan of Correction
Future Annual Reports will also include incoming expenses.
The fiscal manager will be responsible for providing a statement of the annual income and the annual expenses each year to be included in the annual report.
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