INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 30 to October 2, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Esper Treatment Center, 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 and a plan of correction is due on October 28, 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 a review of nine personnel records on 9-30-08 and conversations with the director and lead counselor on 10-1-08, the facility failed to hire a counselor who meets the qualifications. One of five counselors does not meet qualifications for the position.
Finding:
The facility failed to hire a counselor who meets the qualifications for the Bachelors degree level based on lack of experience. The counselor represented by personnel record #5 does not meet the requirement for one year of clinical experience.
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Plan of Correction
Scott T was hired for the In home counseling program. He has 9 months of direct service from his previous employer, which was the Union City school district. He worked with exceptional children in the capacity of providing counseling and group conseling for the exceptional children. His experience is limited to 9 months. Based on his previous experience he has been moved down from counselor to counselor assistant. His supervisor Carol has been monitoring him since his hire date of 8/18/2008. When Carol has monitored him in the field directly for 3 months she will follow up with close supervision, which will mean she will not be in the field with him but will closely monitor his progress. Close supervision will include daily meetings with Scott and monitoring his progress as far as chart work and completion of paperwork is concerned. Carol will be documenting Scott's progress and will keep weekly notes on his progress. When Scott is at the point that he has attained a year of experience he will be moved from counselor assistant to counselor. |
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 review of nine personnel records on 9-30-08 and 10-1-08, seven records were required to have training hours. The facility failed to provide the required number of training hours for two of the seven records.
Finding:
The facility failed to provide the required number of training hours for two counselors for the 2007-2008 training year. Refer to records # 8 and 9.
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Plan of Correction
To ensure that all staff get the required training hours yearly, the Clinical Director has formulated a spreadsheet with all staff and all trainings required along with hours required. The Clinical Director is responsible for alerting the staff to appropriate trainings and letting the staff know how many hours are needed to fulfill the training requirements. The spreadsheet was formulated on 10/6/2008 and will be checked quarterly starting on 10/30/2008. The Clinical Director will check the appropriate web sites for trainings in the area that the staff can attend. |
709.28 (c)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of ten patient records on 10-1-08 and 10-2-08, the facility failed to provide a complete consent to release information form in two of the ten records where required.
Finding:
Consent to release information forms documented in patient records # 3 and 4 failed to indicate who the information would be released to.
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Plan of Correction
To ensure compliance the Clinical Director will hold a training for all counselors and Direct Service staff on how to properly fill out the Release of Information. The training will detail for all staff that the ROI's need to be completed and how to complete the ROI'S before the patient signs them. All counseling and direct service staff are required to attend. This training will be conducted on 10/30/2008. After the training the Clinical Director will be checking ROI's for completeness. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of ten patient records on 10-1-08 and 10-2-08, the facility failed to provide a medical history in five of ten patient records where required.
Finding:
The facility failed to provide medical histories for patient records # 1, 2, 3, 4 and 5.
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Plan of Correction
The records that were not in compliance are from a new program at the Esper Treatment Center. The new program is an In Home Counseling Program for the Office of Children and Youth. ETC provides the outpatient counseling. To ensure that all clients enrolled in the program are getting the medical histories completed the clients will be given the medical histories to fill out when they are filling out the self reporting history. The medical history will be in the inital intake packets for the counselors to use with new clients. The intake packets will include the medical history, the self reporting history and the psychosocial history. It is the resposibility of the counselor to ensure that the medical history is completed along with the other preliminary paperwork. The Supervisor will review the charts of new clients to ensure that all intake paperwork is completed. The intake packets were revised 10/6/2008 and the Supervisor has already started with the audit of new charts as of 10/6/2008 |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of ten patient records on 10-1-08 and 10-2-08, the facility failed to provide and aftercare plan in one of one record where required.
Finding:
The facility failed to provide an aftercare plan in patient record #4.
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Plan of Correction
When a counselor is aware that their client is going to be discharged sucessfully or unsuccessfully they must complete the aftercare plan prior to discharge. A blank aftercare plan will be put into the clients file and will be filled out by the counselor with the client present. The supervisor will review the file and the aftercare plan prior to discharge to ensure that the aftercare plan and all other discharge paperwork is completed correctly. This has been implemented 10/6/2008. |