INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 30 - 31, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Davis Archway House 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:Six personnel records were reviewed on August 30, 2012. Two personnel records pertained to newly hired counselors and required documentation of the qualifications for the position of counselor. The facility failed to provide documentation that employee # 5 met the qualifications for the position of counselor.Employee # 5 was hired for the position of counselor on May 21, 2012 and has a Master's degree in an unrelated field. Employee # 5 does have a Bachelor's degree in a related field but does not possess the one year of required clinical experience. The facility failed to ensure that employee # 5 met the qualifications for the position of counselor.The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Employee #5, who holds a MS degree in Criminology, will be reassigned by the Clinical Supervisor to the position of counselor assistant. Therefore, the counselor assistant will be under close supervision of the Clinical Supervisor for a period of no less than 6 months. The close supervision period shall begin on 9/10/2012 and will be documented at weekly meetings between both parties. The Clinical Supervisor shall review all applicants credentials to assure they have the required education and experience for the position. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to document TB/STD training in one of three personnel records.The findings include:Six personnel records were reviewed on August 30, 2012. Three personnel records required documentation of TB/STD training. The facility failed to document TB/STD training in personnel record # 3.Employee # 3 is a counselor and was hired on June 29, 2011. TB/STD training was due to be completed no later than June 29, 2012. The facility failed to document TB/STD training as of August 30, 2012.The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Clinical Supervisor scheduled employee #3 for the required TB/STD training and will complete the hours on 9/30/12. The Clinical Supervisor will review employee training records quarterly to ensure communicable disease training is scheduled as required for all employees. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the facility's staff schedules and CPR certification cards, the facility failed to ensure that at least one person trained in CPR was onsite during the project's hours of operation.The findings include:Staff schedules for August 5 through August 31, 2012 and employee CPR certification cards were reviewed on August 30, 2012. The facility provides residential treatment and rehabilitation services 24 hours per day. The facility failed to ensure that at least one person trained in CPR was onsite from 4:00 PM through 11:30 PM on the following dates: August 5, 2012, August 12, 2012, August 19, 2012 and August 26, 2012.The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The employee in question was a trained EMT and it was assumed he held certification in CPR/First Aid. Unfortunately his CPR had expired at the beginning of 2012. Therefore, the Clinical Supervisor had the employee attend CPR class on 9/13/2012 and he is now fully certified. The Clinical Supervisor has noted for future reference that EMT certification will not replace the CPR certification. The Clinical Supervisor will review the staff schedules monthly to ensure there is 24 hour CPR and first aid coverage for all shifts. |