INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 12, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Stairways Behavioral Health Outpatient Drug and Alcohol Program 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
The facility failed to ensure that the staff person hired as the project director met the educational requirements in one of one record reviewed on April 12, 2017.
A review of personnel record #1 documented a Licensed Practical Nurse license. This does not meet the educational requirements.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current facility director will be appointed by the board as the project director at the next board meeting, May 19th, 2017. DDAP will be notified via email of this change.
The facility director reviewed the project director regulations with Human Resources on 4/18/17 to ensure that this deficiency does not happen in the future.
It is the responsibility of the facility director to ensure that the corrective action is implemented. |
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 ensure that each counselor met the qualifications for the position in one of three personnel records reviewed on April 12, 2017.
Eight personnel records were reviewed. Three records were reviewed as new counselors.
Employee # 8 has a Bachelor of Arts in Dance. This does not to meet the educational requirements for the position of counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This employee signed a job description for Counselor Assistant on 4/18/2017. This employee has previously completed counselor assistant supervision, for which this agency has the documentation. This employee will register and complete the CADC examination by 10/28/17. Upon receipt of the certification, this employee will be eligible for the position of Counselor.
The guidelines for educational requirements were reviewed with Human Resources on 4/18/2017 to prevent future issues.
It is the responsibility of the Facility Director to ensure that the corrective action is implemented. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The facility failed to ensure privacy so that counseling sessions cannot be seen outside the counseling room.
Windows in two counselor offices did not have a covering, allowing persons outside the counseling office to see inside.
One counselor's office had a window that did not have a covering, allowing persons in the parking lot to see into the office.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Window coverings have been ordered and will be installed no later than 5/15/2017. Temporary window coverings were placed over windows on 4/13/2017 to ensure confidentiality until the permanent coverings are installed.
It is the responsibility of the Facility Director to ensure that the corrective action is implemented. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to document the exit routes used during fire drills.
Fire drill logs from May 2016 to March 2017 were reviewed on April 12, 2017. The facility failed to document the exit route used during all fire drills reviewed.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
The Fire Drill Log form will be modified to provide identification of the exit routes utilized during each fire drill. This action will be completed by 6/1/2017.
It is the responsibility of the Facility Director to ensure that the corrective action is implemented. |