INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from January 30 to February 1, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Treatment Services 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 upon the review of employee records, the facility failed to provide documentation that counselors met the credential and/or experiential requirements for the position in two of two employee records.
The findings include:
Five employee records were reviewed on January 31, 2013. Two employee records were reviewed that required documentation of credential and/or experiential requirements for the position of counselor. The facility failed to provide documentation that verified that an individual hired to be a counselor met the experiential requirements in employee records # 4 and 5.
Employee # 4 was hired as a Bachelor's level counselor on August 26, 2012. As of the date of inspection, the record did not include documentation of the required clinical experience.
Employee # 5 was hired as a Bachelor's level counselor on May 23, 2011. As of the date of inspection, the record did not include documentation of the required clinical experience.
The findings were confirmed by the Project Director during the record review.
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Plan of Correction
Employee #4: Due to confusion on our part the employee was promoted to a counselor position after working as an intake worker for 18 months.
In order to rectify the current situation her immedaite supervisoy has already started close supervision and will document these sessions weekly. The standards set forth under 704.9 will be followed. The supervisor will report directly to the Project Director.
Employee #5: We will be asking for an exemption for employee #5's status. We believed that when she was hired she met the qualifications of Counselor after spending a full school year interning at this Agency and receiving a BSW.
Employee #5 will be supervised as a Counselor Assistant pending the outcome of the exception request. The standards set under 704.9 will be followed with the Supervisor reporting directly to the Project Director.
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709.28(c)(2) 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 include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based upon the review of client records, the facility failed to document informed and voluntary consent forms to include the specific information to be disclosed in three of ten client records.
The findings include:
Clients engaged in an intake process prior to being admitted. The intake process included an orientation to the program as well as the signing of documents such as consent forms.
Ten client records requiring informed and voluntary consent forms were reviewed from January 31 - February 1, 2013. The facility failed to document consent forms to include the specific information to be disclosed in client records # 2, 7 and 13.
Client # 2 was admitted on April 16, 2012, and was still an active client on the date of inspection. The record contained a consent form that was signed by the client on March 22, 2012, that did not include the specific information to be disclosed.
Client # 7 was admitted on December 20, 2012, and was still an active client on the date of inspection. The record contained a consent form that was signed by the client on August 20, 2012, that did not include the specific information to be disclosed. The record also contained three consent forms that were signed by the client on September 5, 2012, that did not include the specific information to be disclosed.
Client # 13 was admitted on January 17, 2013, and was still an active client on the date of inspection. The record contained two consent forms that were signed by the client on October 23, 2012, that did not include the specific information to be disclosed.
The findings were confirmed with a clinical supervisor during the record review.
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Plan of Correction
An in-service will be held on March 7, 2013 to address this issue. The Clinical Director and Clinical Supervisors will be responsible for re-training staff relating to informed and voluntary consent forms. A focus will include the need to identify specific information to be disclosed and its limitations.
The Clinical Director will be responsible for continued oversight. This concern will recieve special attention in quarterly case file reviews. |
709.28(c)(3) 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 include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based upon the review of client records, the facility failed to document informed and voluntary consent forms to include the purpose of the disclosure in three of ten records.
The findings include:
Prior to being admitted, clients engaged in an intake process that could take place over three to five sessions. The intake process included the signing of documents such as consent forms.
Ten client records requiring informed and voluntary consent forms were reviewed from January 31 - February 1, 2013. The facility failed to document consent forms to include the purpose of the disclosure in records # 2, 7 and 13.
Client # 2 was admitted on April 16, 2012, and was still an active client on the date of inspection. The record contained a consent form that was signed by the client on March 22, 2012, that did not include the purpose of the disclosure.
Client # 7 was admitted on December 20, 2012, and was still an active client on the date of inspection. The record contained a consent form that was signed by the client on August 20, 2012, that did not include the purpose of the disclosure. The record also contained three consent forms that were signed by the client on September 5, 2012, that did not include the purpose of the disclosure.
Client # 13 was admitted on January 17, 2013, and was still an active client on the date of inspection. The record contained two consent forms that were signed by the client on October 23, 2012, that did not include the purpose of the disclosure.
The findings were confirmed with a clinical supervisor during the record review.
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Plan of Correction
An in-service will be held on March 7, 2013 to address this issue. The Clinical Director and Clinical Supervisors will be responsible for re-training staff relating to informed and voluntary consent forms. A focus will include the need to identify specific information to be disclosed and its limitations.
The Clinical Director will be responsible for continued oversight. This concern will recieve special attention in quarterly case file reviews.
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