INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 4, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Beal Counseling and Consulting 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 records, the facility failed to ensure that each counselor met the qualifications for the position in one of one personnel records.
The findings include:
Four personnel records were reviewed on October 4, 2011. One personnel record pertained to a new counselor and was required to include documentation of the qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in one of one counselor's personnel record, specifically, record # 4.
Employee # 4 was hired as a counselor on February 21, 2011. Employee # 4 has a Bachelor of Science degree in an approved related field; but did not have documentation of one year of required clinical experience at the time of the review, on October 4, 2011.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Employee#4 was able to confirm a paid internship with a previous employer that covered 3 months. The experience Employee #4 has obtained with this facility covers 8 months.
As of 10/13/2011 the Employee has been reclassified as a counselor assistant for 1 month. During this time close supervision will be provided. At the conclusion of that time the employee will be re-classified as a counselor.
The Project Director will ensure close supervision is completed and documented for employee # 4. The Project Director will ensure that any new clinical staff will receive the required supervision; if they do not meet the qualifications for the position of counselor. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to document the required period of close supervision for one counselor assistant.
The findings include:
Four personnel records were reviewed on October 4, 2011. One of the four personnel records pertained to the position of counselor assistant and required documentation of close supervision. The facility failed to document the required close supervision in one of one counselor assistant's personnel record, specifically record # 4.
Employee # 4 was hired on February 21, 2011. Employee # 4 has a Bachelor of Science degree in an approved related field; but did not have one year of required clinical experience. Employee # 4 meets the qualifications for the position of counselor assistant; and was required to have close supervision for at least the first 6 months of employment. Personnel record # 4 did not include documentation of the required close supervision at the time of the review, on October 4, 2011.
The project/facility director was interviewed throughout the licensing process and confirmed the required close supervision of employee # 4 was not documented.
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Plan of Correction
Employee#4 was able to confirm a paid internship with a previous employer that covered 3 months. The experience Employee #4 has obtained with this facility covers 8 months.
As of 10/13/2011 the Employee has been reclassified as a counselor assistant for 1 month. During this time close supervision will be provided. At the conclusion of that time the employee will be re-classified as a counselor.
The Project Director will ensure close supervision is completed with this employee. The Project Director will ensure that any new clinical staff will receive the required supervision; if they do not meet the qualfications for the position of counselor. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the frequency of treatment and rehabilitation services in the client treatment plans.
The findings include:
Six client records were reviewed on October 4, 2011. Four client records required documentation of an individual treatment and rehabilitation plan. Per regulation, an individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of type and frequency of treatment and rehabilitation services. The facility failed to document the frequency of treatment and rehabilitation services in client records # 1, 3, 4 and 5.
Client # 1 was admitted into treatment on July 26, 2011. An individual treatment and rehabilitation plan was developed with the client on August 15, 2011. The client is receiving individual counseling sessions. The treatment plan did not specify the frequency of these treatment and rehabilitation services.
Client # 3 was admitted into treatment on July 19, 2011. An individual treatment and rehabilitation plan was developed with the client on September 1, 2011. The client is receiving individual counseling sessions. The treatment plan did not specify the frequency of these treatment and rehabilitation services.
Client # 4 was admitted into treatment on January 31, 2011 and discharged on March 23, 2011. An individual treatment and rehabilitation plan was developed with the client on February 21, 2011. The client is receiving individual counseling sessions. The treatment plan did not specify the frequency of these treatment and rehabilitation services.
Client # 5 was admitted into treatment on February 24, 2011 and discharged on March 14, 2011. An individual treatment and rehabilitation plan was developed with the client on March 8, 2011. The client is receiving individual counseling sessions. The treatment plan did not specify the frequency of these treatment and rehabilitation services.
The project/facility director was interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
The project director created a new form (10/12/2011) that includes the type and frequency.
Staff were retrained on 10/13/11 regarding the use of this form.
The project director will ensure this deficiency does not recur by client record reviews during the time of treatment plan signature and during treatment plan reviews. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document quarterly case consultations, as per facility policy and regulation.
The findings include:
Per facility policy, a case consultation will be completed quarterly.
Six client records were reviewed October 4, 2011. The facility failed to document case consultations in one of one record requiring them, specifically, client record # 6.
Client # 6 was admitted into treatment on July 25, 2010. Case consultations were due to be completed no later than December 31, 2010, March 31, 2011, June 30, 2011 and September 30, 2011. There was no quarterly case consultations documented at the time of the review, on October 4, 2011.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Program Director has corrected this deficiency by developing the Case Consultation form (developed on 10/12/2011)and training the staff on its use. This training occurred on 10/13/2011. The Program Director will ensure that the Case Consultations occur and are documented on a quarterly basis at a minimum through client record reviews.
A case consult for client #6 was completed on 10/13/2011 |