INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 16, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Creative Health Services, Inc. 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 and the Staffing Requirements Facility Summary Report (SRFSR), the facility failed to ensure that each counselor met the qualification for the position of counselor.The findings included: On February 16, 2016, eight personnel records were reviewed for documentation of the qualifications for the position of counselor.The facility failed to ensure that each counselor met the qualification for the position of counselor, specifically employee #6.Employee # 6 was hired as a counselor on January 7, 2016. Employee #6 did not meet the qualifications for the position of counselor based on a Bachelors in English Literature degree which does not meet the education requirements. These findings were discussed with facility staff during the licensing process.
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Plan of Correction
By 2/29/2016 the facility director will monitor any new hire position to ensure that each counselor meets the qualifications for the position of counselor. The facility director will be responsible for ensuring staff meet qualifications per DDAP regulations. The current identified staff, employees #6 is reclassified as a counselor assistant effective, 2/16/2016. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and active client list, the facility failed to comply with the maximum approved capacity for the outpatient activity. The findings include:The Staffing Requirements Facility Summary Report was reviewed on February 16, 2016. The summary report, signed by the Project/Facility Director, indicated the facility had 125 current clients in their outpatient program. The facility is licensed by the Division for a maximum client capacity of 120 for their Outpatient Drug-Free license. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 2/29/2016 Facility director will conduct a follow up on previously paperwork submitted to DDAP 11/15 requesting capacity increase. The facility director will be responsible for notifying the department (DDAP)within 90 days of the occurrence of any change in authorized maximum capacity. The facility director will monitor capacity levels for current clients and place anyone on a waiting list if the agency reaches full capacity. |