INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on October 17-18, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Center for Behavioral Health-PA, 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 the 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
The facility failed to document that each counselor met the qualifications for the position of counselor.
The personnel and training records were reviewed on October 17, 2016. Employee #7 was found to not meet the qualifications for the position of counselor.
Employee #7 was hired as a counselor on 9/7/16. Employee #7 holds a Bachelor of Arts degree in Italian, which does not meet the qualifications for the position of counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #7 has been moved to a counselor assistant as of 10/27/2016. Direct observation and increased supervision has begun. Employee #7 has been provided with the CADC application and will begin the process to become certified. Employee #7 training plan has been updated to reflect her new training needs.
Clinical Supervisor will provide the direct observation and supervision. Clinical Supervisor will assist employee #7 through the CADC application and testing.
Moving forward, Clinical Supervisor and Clinic Director will ensure the counselor candidate will meet the educational and experience identified in regulations prior to hire.
Clinic director will oversee. |
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
The facility failed to document 25 clock hours of training for each counselor for the 2015 training year.
The personnel and training records were reviewed on October 17, 2016. The 2015 training year was reviewed, which covers January through December. Employee #4 did not have at least 25 clock hours documented for the 2015 training year.
Employee #4 was hired as a counselor on 11/12/13. Employee #4 completed 20.25 hours of training for the 2015 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure that all staff obtain the minimum required training, supervisors will monitor training attendance monthly. At this time, all staff are scheduled to attend training to meet his/her minimum training requirements for the current year.
Clinical Supervisor will maintain the training offered and suggest training according to individual needs. Clinical Supervisor will ensure that training needs are met for each staff.
Clinic Director will oversee. |