INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 31, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Community Service Foundation, 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 files, the facility failed to ensure that each counselor met the educational and experiential qualifications in one of one applicable personnel record reviewed.
Employee #5 was hired as a counselor on October 24, 2022. The employee did possess the required degree with a major in a related field; however, the employee did not have the required 1 year of clinical experience in a health or human service agency, prior to hiring.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #5 was hired as a counselor on October 24, 2022. The employee did possess the required degree with a major in a related field; however, the employee did not have the required 1 year of clinical experience in a health or human service agency, prior to hiring. The clinical supervisor will ensure that prior to hiring a new employee, counselor and counselor assistant qualifications will be reviewed to see what the potential employee will qualify as. The facility director will ensure the clinical supervisor reviews potential employee qualifications prior to hiring them as a counselor or as a counselor assistant. Training of the clinical supervisor will be completed by 3/31/2023. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were being provided according to the individual treatment and rehabilitation plan in four of eight client records reviewed.
Client #1 was admitted on May 26, 2022 and discharged on December 8, 2022. The individual treatment plan, completed on June 2, 2022, indicated the client was to receive a weekly group counseling session. There was no documentation, in the record, of group counseling sessions being provided to the client throughout the entire treatment episode.
Client #2 was admitted on May 27, 2022 and discharged on September 16, 2022. The individual treatment plan, completed on June 1, 2022, indicated the client was to receive a weekly group counseling session. There was no documentation, in the record, of group counseling sessions being provided to the client during the weeks of June 5, 2022 - July 23, 2022.
Client #4 was admitted on June 17, 2022 and discharged on September 30 2022. The individual treatment plan, completed on June 29, 2022, indicated the client was to receive a weekly group counseling session. There was no documentation, in the record, of group counseling sessions being provided to the client throughout the entire treatment episode.
Client #8 was admitted on November 15, 2022 and was active at the time of the inspection. The individual treatment plan, completed on November 17, 2022, indicated the client was to receive a weekly group session. There was no documentation, in the record, of group counseling sessions being provided to the client during the weeks of November 20, 2022 - January 7, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure that counseling services were being provided according to the individual treatment and rehabilitation plan in four of eight client records reviewed. The clinical supervisor will ensure that the individual treatment and rehabilitation plan reflects the counseling services that will be provided to the client through regular client file checks to ensure this will not occur again. Staff will be trained and supervised by the clinical supervisor to ensure the client's individual treatment and rehabilitation plan reflects the counseling services that will be provided. Training of all staff will be completed by 3/31/23. |