INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 18, 2915 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Services of Warren County 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 two personnel records.
The findings include:
Three personnel records were reviewed on March 18, 2015. Two personnel records were required to have documentation of the qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel record # 3.
Employee # 3 was hired as a counselor on July 18, 2015. Employee # 3 has a Bachelor of Science in Cultural Studies and a Masters of Art in Spiritual Formation. There were no transcripts for either degree documented. The degrees do not meet the educational component for the position of counselor.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility director/program director will transfer unqualified employees current cases to a qualified staff by April 7, 2015 to regain compliance. The facility director/program director will review regulation 704.7 in detail and review with Human Resource Manager.
When hiring or transferring new staff the facility director/program director will assure the potential employee has a degree that fits the criteria for regulation 704.7. Program and facility director will obtain a copy of the potential employee's transcripts and review with Human Resource Manager prior to hiring staff.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to instruct staff in the use of the fire extinguishers upon staff employment in one of one record.
The findings include:
Three personnel records were reviewed on March 18, 2015. One record was reviewed as a new hire. There was no documentation in personnel record # 3 that the employee was instructed in the use of the fire extinguishers.
Employee # 1 was hired by the facility on July 18, 2005. He was hired as a drug and alcohol counselor on July 21, 2014. There was no documentation provided that the employee was instructed in the use of the fire extinguishers upon employment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director/program director will review fire safety/use of fire extinguisher with employee and document training took place by April 6, 2015.
Facility Director/program director will train each new staff in fire safety/use of fire extinguishers by the 5th day of employment. Once the training has been completed the employee and facility director/program director will sign and date proof of training and place in personnel record.
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705.21 (2) LICENSURE General req. for nonresidential facilities.
705.21. General requirements for nonresidential facilities.
The nonresidential facility shall:
(2) Have a certificate of occupancy from the Department of Labor and Industry or its local equivalent.
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Observations
Based on a physical plant inspection and the review of the policy and procedure manual, the facility failed to provide documentation of a certificate of occupancy from the Department of Labor and Industry or its local equivalent, as required.
The findings include:
A physical plan inspection and the review of the policy and procedure manual was conducted on March 18, 2015. There was no documentation provided of a Certificate of Occupancy from the Department of Labor and Industry or its local equivalent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The certificate of Occupancy was obtained and produced on 3-19-15 by facility director and faxed to the number on the licensing specialist's business card. Facility director placed the certificate of occupancy in the policy and procedure manual on 3-19-15. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a review of the record keeping system, the facility failed to enure that the electronic client records were stored on a secure, password protected data base.
The findings include:
The record keeping system was reviewed on March 19, 2015. The electronic record keeping system was not secure and it allowed for the possibility of staff who are not part of the client's drug and alcohol treatment team to access the record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility director will inform staff on 4-13-15 that all documentation regarding clients in the substance abuse treatment program will stop and documentation will return to paper charting.
Facility director will work with each therapist to assure all existing electronic records for substance abuse clients are printed and a paper chart will be developed. After electronic records have been printed facility director will remove substance abuse electronic records from electronic health records system. |
709.28(c) 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:
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client that adhered to 4 Pa. Code 255.5 in one of ten client records reviewed.
The findings included:
Ten client records were reviewed on March 18, 2015. Ten client records required an informed and voluntary consent. One client record included a consent for their employer. The release of information to an employer is restricted to 4 Pa. Code Subsection 255.5(a)(6) which states that " information shall be limited to whether the client has or is receiving treatment with the project".
Client # 9 was admitted on January 5, 2015. A consent for their employer, signed by the client on January 15, 2015, allowed for the disclosure of the client's prognosis, a brief description of the progress of the client and a statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse. This information exceeded the specific information permitted to be disclosed to the employer.
A letter dated January 22, 2015 was sent to the client's employer. The letter documented the name of the substance abused by the client, how many sessions the client attended and the counselor's opinion on whether or not the client was able to return to work. This exceeded what is permitted to be released to an employer.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director/program director will meet with staff individually and as a group to specifically review 4Pa. Code Subsection 255.5 (a)(6) by 4/10/2015. Facility Director/program director will provide print out of 255.5. Projects and coordinating bodies: disclosure of client-oriented information and disseminate to staff to have on hand for review when disclosing information. Facility Director/program director will document training and place in personnel records. Facility Director/program director will review clinical charts at least quarterly to assure compliance. |